142 Irishman Place Lot 26arruw►uuN roll SITE EVALUA710N/IMPR0V MENT PERMFF dt A
Davie County Health Department D D
Envhonment7/flea/th SftW0n
P.O. Box 848/210 Hospital Street NOV 16 Iggg
Moaksville, HC 27028
(336)751-8760
ENVIRONMENTAL HEALTH
nNEGUM
***IMPORTANT**+.:THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the IN80Rt•4►TION BULLETIN fox instructions.
1. soon to be Blllod—&MA NDYWICVI 1IJ ,�c,L1 I ✓fi✓
contact parson _
Nailing Address�. D �c»C 1 Rome phone - JIM —4/n/
city/state/zip VGhtJQ All 27x)0( Business Phone _ /V0 -( /D
a. Name on permit/ATC if Different than Above
Nailing Address
3. Application For: ❑ Site Evaluation
e. system to Service: M/
House ❑ Mobile Home
S. If Residence:
KDishwasher
# People
C
_it
tyy/state/zip
iS Improvement Permit/ATC ❑ Both
❑ Business ❑ Industry ❑ Other
# Bedrooms 3 # Bathrooms Z
D Garbage Disposal $$Washing Machine
6. if Business/Industry/Other: specify type
It cOuniOdes # showers
IF rooD317 CE: i 'Seats
7. Type of water supply:
O 828amMot/Plumbing D Basement/No Plumbing
# People - # Sinks
# Urinals # water Coolers
Estimated Water Usage (gallons per day)
)County/City
0 Nell
e. Do you anticipate additions or expansions of the facility this System is intended to serve?
H yes, what type?
0 Community.
0 Yes )(No
""PORTANT'" CLIENTS MUST COAfPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: /6A ?( 378 )c 10 0 )e 32P
Tax Ofiice PIN: # 1 i� �- �3- 13�j'
010 A14
Property Address: Read Name, PleLt
')51- 3y« City/Zip i AV4L\,,-e— Vloou
If in a Subdivision provide information, as. follows:
Name: )tA0- CbGV 14iV'eb
Section: "1% Block: Let. l0
WRITE DIRECTIONS (from Mochsrllle) to PROPERTY:
Tie- 1-Z Z"d perm ks Greeff
Y�S�'� L✓j'Si�In�a�. t"�^t�h Y'�5v-cS
Date Property Finned: _ 11 -Ig -2,2
This 6 to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
Issued hereafter are subject to suspension or revocation, if the site plans or Intended use change, or if the information
submitted lin this application Is falsified or ebanged. 1, OLso, understand that I ani roponsib/e for all charges Incurred from
this apPUcatiom 1, hereby, give consent to the Authorized Representative of theme a County Heallh Department
WA
to enter upon above described property located in Davie County and owned by / GSM A p all
to conduct all testing procedures as necessary to determiBe the site salla ility. Q 1 - -
DATE I I — 1 U SIGNATURE %� et� 1 L7 `1
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
Property lines and dimensions, structures, setbacks, and septic locations).
Revised DCHD (07/98)
M
Account No. /
Invoice No. -3a7 to
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME '
ADDRESS'�"v���'
PROPOSED FACIILTY
DATE EVALUATED 9jS /9S J
PROPERTY SIZE Y� G
LOCATION OF SITE
Water Supply: On -Site Well Community Public t_—
Evaluation
Evaluation By: Auger Boring Pit C1___ Cut
FACTORS 1 2 3 4
Landscape position
Slope R
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure / S
Mineralogy`
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: P
LONG-TERM ACCEPTANCE RATE: '
REMARKS:_
DCHD(01-901
EVALUATED BY: Ila `/
' OTHER(S) PRESENT:
LEGEND
Landscape Position
R -Ridge S -Shoulder L -Linear slope FS -Foot slope N -Nose slope
CC -Concave slope CV -Convex slope T -Terrace FP -Flood plain H -Head slope
_Texture
S -Sand LS -Loamy sand SL -Sandy loam L -Loam SI -Silt
SICL-Silty -;lay loam SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
Moist
VFR-V,,.-y friable FR -Friable FI -Firm VFI-Very film EFI-Extremely firm
Wet
NS -Non sticky SS -Slightly sticky S -Sticky VS -Very Sticky
NP -Non plastic SP -Slightly plastic P -Plastic VP -Very plastic
Structure
3C -Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky
SBK-Subangular blocky PL -Platy PR -Prismatic
Mineralogy
1:1, 2:1, Mixed
Notes
Horizon depth - in inches
Depth of fill - In inches
Restrictive horizon - Thickness and inches from land surface
Saprolite - S(suitable), U(unsuitable)
Soil wetness - Inches from land surface to free water or inches from land surface to soil colors
with chroma 2 or less
Classification - S(suitable), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2
I `ty1vy6
T46 1ZATION N&,,l "194 ,; DAME. OUNTY HEALTH DEPARTMENT.''.
j Environmeal Health Section PROPERTY INFORMATION
nt
miree s , p� i P O Box 848 ' {`a�����
de !/,ill�,✓ete •��Y�1�.to� i >\n...i.�.,.no,ntro�mst Subdivision Name: �,f/stf`�
r System Construction` MUST BE ISSUED by the Davie CountyEnvironmental Health Section prior
s. This Form/Authoriiation Number'should.be presented to the'Davie County BuildingInspections
Permits
130A, Wastewater Systems; Sect oh ] 900 Sewage Treatment and Disposal Systems)
�r***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
i.. IS VALID FOR A PERIOD OF FIVE YEARS
TE ISSUED