284 Brangus Way Lot 32-33DAVEE COUNTY ]HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990004056 Tax PIN/EH #: 5832-18-5343
Billed To: Cortland Meader Subdivision Info: Whip-o_will Lot# 32
Reference Name: Location/Address: Brangus Way -27028
ATC Number: 4465 As stated in 15A NCAC 18A.1969(5)
accepted Systems may also be used
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
NOTE This Authorization for Wastewater System Construction NIUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article I I of
G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatm It d Disposal Systems). THIS
V�
AUTHORIZATION FOR WASTEW S A DT011, RIOD OF EIVE YEARS.
t
Environmental Health Specialist's Signature. C) C47
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
has been installed in compliance with Article I I of G.S. Chapter 130A, Section. 1900 "Sewage Treatment and
Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any
given period of time. V:4trl,
60,
lem &jt-\L-
"TACS."3 V- bnzTe
-S'17;6 Sep�ic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
.. -V
Lp
A
A 10
4%
1�\
4WCk
A(
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT(OPERATION PERMIT
Account #: 990004056
Billed To: Cortland Meader
Reference Name:
Proposed Facility: Residence
Tax PIN/EH #: 5832-18-5343
Subdivision Info: Whip -o -will Lot # 32
Location/Address: Brangus Way -27028
Property Size: 5.46 ares
WAumlier: 4465
**NO 'Ibis mprovement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this
Department prior to the construction/installation of a system or the issuance of a building permit (in compliance with
Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS
PERMIT IS SUBJECT TO REVOCATION ]IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type $nE- #People #13edrooms #Baths S. ��-
Dishwasher: El Garbage Disposal: El Washing Machine: El Basement w/Plumbing: 12"' Basement/No Plumbing: El
Commercial Specification: Facility Type #People _ #People/Shift #Seats Industrial Waste:
Lot SizeSdG 026 e Water Supply O -WWW Design Wastewater Flow (GPD) -72D Site: New Ce -r"' Repair
System Specifications: Tank lize 7fAL. Pump Tank GAL. Trench Width--:�L;' Rock Depth JZ % I Linear Ft.qeZ0
Other: Opalm-boji- 0'.1 -ZDXeS>, Lxdw&Tlr�,�q V�Dvj -/A-\1e
r
\t.�SST&LA_ 0,� LZ-1�0.,(2
Required Site Modifications/Conditions: 11-3' QE��
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this
system between 8:30 a.m. to 9:30 a.m. or 1:00 p. to 1:30 p.m. on the day of installation. Tele ne # is (336)751-8760.
As stated in 15A NCAC 18A.1969(5
AN( Af%rPP14Systerns inay also be usN
ronment Heal PhSr
DCHD 05/99 (Revised)
1W
<
Signature:
1-:2 4
ta
12.5'
52
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PETTIn
Davie County Health Department !�,i
Environmental Health Section H!
P.O. Box 848/210 Hospital Street 2DO6
=AUG
Mocksville, NC 27028
(336)751-8760/ Fax (336)751-8786 ENviRoNV,,E1JTAL HEALTH
DAVECOUNTY
Application For: 0 Site Evaluation/Improvement Permit eAuthorization To ConstruL 0
***IMP0RTANP** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed 2' Contact Person
Billing Address 2_0S -5Q, —Home Phone
City/State/ZIP - I- -) - > D]!�, Business Phone
Name on Permit/ATC if Different than Above
Mailing Address
PROPERTY INFORMATION
NOTE: A surveyplat or site plan must accompany this application.
(Permit is validfor 60 mon s wZte 131an, no qxpiration with complete plat.)
I SWA"f City M0C;V-5J)LLL-TaxP
Street Address 7164 V�_ --?U IN# �113
Subdivision Name___W�AIV 0 V3)1
Section/Lot# Lot Size
Directions To Site:
Date House/Facility Comers Flagged
If the answer to any of the following questions is "yes", supporting documentation ust be attached.
An
Are there any existing wastewater systems on the site?
Dyes
wo
Does the site contain jurisdictional wetlands?
Dyes
Are there any easements or right-of-ways on the site?
[]Yes ff90
Is the site subject to approval by another public agency?
D Yes ff-9
ZO
Will wastewater other than domestic sewage be generated?
Dyes
IV Xh�)IUENUP, PILL UU I IMP, JJUA JJELUW I---- Z
# People # Bedrooms (d 4r]�athrooms Garden Tub/Whirlpool ffYes DNo
Basement: FY, -,es ONo Basement Plumbing: _�'Yes DNo
IF NON -RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business Total Square Footage of Building # People
# Sinks # Commodes # Showers # Urinals
Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: # Seats
Type system requested: J21conventional DAccepted DInnovative E]Altemative 00ther
Water Supply Type:/County/City Water 0 New Well DExisting Well 1 0 Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes
If yes, what type?
0 No
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that
any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if
the information submitted in this application is falsified or changed. I understand that I am responsiblefor all charges incurred
from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to
conduct necessary inspections to determine compliance with applicable laws and rules on the above described property located in
Davie County and owned by
Site Revisit Charge
Property owner's or o4er's legal representative signature Date(s):
4 0 Client Notification Date:
DateU EHS:
Sign given Dyes DNo Account #
Revised 2/06 Invoice #
AUTHOIIIZATION NO. JUAVIE COUNTY HEALTH DEPARTMENT
7 3 4,
Environmental Health Section PROPERTY INFORMATION
P;rmittee's P.O. Box 848
Name:
6 Mocksville, NC 27028 Subdivision Name: 1. 1
L�� I LL.
Directions to property: 70 CA Phone # 336-751-8760 Section: Lot: -S-2`4
AUTHORIZATION FOR
WASTEWATER
12, tj SYSTEM CONSTRUCTION Tax Office PIN:# 5-�.32-- 3 3
-70
rrc t,)J L4( --ii —I Road Name: hiqiD: 2 7t) 4- 4��
"NOTE"This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits. This Form/Authorization Number should be presented to the bavie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article I I �f G.S. Chapter 130A, Wastewater Systems, Section. 1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
[VIRON*'NYAL HEALTH SPECIA�IS DATE ISSUED
DAVIE, OUNTY HEALTH DEPARTMENT
1.7 3A 7,j IMPRIIE I MENT AND OPERATION PERMITS PROPERTY INFORMATION
P e
-N Subdivision Name: j I 1 (,0 L L k
Directions to property: A, e- Section:
—Lot:.
IMPROVEMENT
PERMIT Tax Office PIN:
–V
Road Name: Zip: Z A, 2`9
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An
AUTI-IORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained fi-om this Department prior to the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article I I of G.S. Chapter 130A, Wastewater Systems, Section. 1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
'PLANS OR THE DITENDED USE CHANGE. YOUR WASTEWATER
�SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
iHEALTH SPECIALIST DATIIISSOED -
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE #BEDROOMS 1�4 #BATHS1'�> #OCCUPANTS GARBAGE DISPOSAV
,Yes �r No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE 10 Y (�01 )A�l NEW S
TYPE WATER SUPPL SIGN WASTEWATER FLOW (GPD REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE 1000GAL. PUMP TANK GAL. TRENCH WIDTH
t, ROCK DEPTH LINEAR FT
L)
OTHER 5 '04 V'F1 101 J -aX&7Z d V4
REQUIRED SITE MODIFICATIONS/CONDITIONS: ld5pqtt, Or) J-ttvaa XL- - P R3
IMPROVEMENT PERMIT LAYOUT
KJILIX
V,j IN. -a I
TY2 I V�
S�
"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY-
AU'rHORIZATION NO. OPERATION PERMIT BY: DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I I OF G.S. CHAPTER 130A, SECTION. 1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96 (Revised)
"N_
-LTH DEPARTMENT
DAVTE� OUNTYHEA
0 MENT AND. OPERATI ON PERMnS
-PwfPRo PiZOPtRTY,INFORMATION
Ame, SubdiVision Name:
-Yeh,
7
tions .",.Section: .,Lot:,
t9spro
irerty:'(1
I&
52,
'Roa
4AS
A. tlj Name: 11 CLN
**NOTE�*Tliis ImMvem6rit Pi:imit DOES NOT awlorize.the construction or iistaUatioribf a septitc-tank system or any wastewater system. An
t
AUTHORIZAMON FOR WASTEWATER SYsTEmcoNsTRucrioNmusibe o6taindfium-this-Depprtment prior to the
'a s�steirioi building'permi
construction/instaffation bi the issuance of a L.
'(In-compfiance with Articlel 16f G.�.' Sy*nls, Section . 1900 Sewage Treatmen
qmp�ff t3OA� Wastewater t and Mposal Systems)'
*P,*N0TICE4 PERMIT I$ SUBJECT TOREVOCATION IF SITE
t ATER-
,,11 g - I SORTHIff 4TENDE&USECHAlY
,GLYOURWASTEW
I CLC. ISS D,3
CONTRACTOR,MUST SEE TOTS PERM
A TH Sl DA Ift IT BEFORE
INSTALLINGTHE.SYSTEM.7
RESIDENTIAL SPECIFItATION:.tUILDING TYPE �BEDROOMS # BATHS # OqqUPANTS 4 GARBAGE DISPOSAi� No
COUNMCIAL'SPECIFICATION:.FACILrrYT�PE' #,PEOPLE -#PEoPLE/sHiFr SEATS -INDUSTRIAL WASTE: Yes, or No
10 ACA
LOT SIZE TYPE WATER.SUPPLY i�a �"IGN WASTEWATER FLOW (GPD)!q$?O' NEW Siili.� 'REPAIR SITE
SYSTE.MS,PECIRCATIONS:,,TANKS12E:ltjD6GAL. PUMPTANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR Fr.
OTHER BAZI7Z' )j A 1, Ile
jva42
- /,�;
IEQump SITE mpDiFicAnoNs/coNDmpN9:' beT e� cri.
: A-
**COgNTACTAREPRESENT.AnVEOFTHE'DAV OUNTY HEALTHPEPARTMENT FOR FINAL INSPECTION OF TIES SYSTEM,
BEn
1:30 P.M. ON THE 15AV OF INSTALLATION. TELEPHO i IS
ETWEEN 8:30' 9:30A.M..OR,1:00 NE (336)751-8160.*
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC
Davie County Health Department
Environmental Health Section LP
P. 0. Box 848
Mocksville, NC 27028
(704) 634-8760 OCT 2 6 10
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCES DU&il�"E§,.,.'tFlITt.LifFt.LTII
ALL THE REQUIRED INFORMATION IS PRk "I.1,11TY . —A
T_
,i_hN,o f +JJ Ep
1. Name to be Billed ContactPerson 0-10AT
Mailing Address T --r- IF-ro 13 �) —1. Home Phone
City/State/Zip P C, 0 . t\J(, � 7 o o c,- Business Phone b 5-9- q78 9
2. Name on Permit/ATC if Different than Above
Mailing Address City/State ip
3. Application For: Site Evaluation provement Permit & ATC 04"Both
4. System to Serve: a/ House Q Mobile Home El Bus iness El Industry Ll Other
5. If Residence: # People # Bedrooms # Bathrooms Z/"S-
/Dishwasher O/Garbage Disposal (14ashing Machine M/Basement/Plumbing El Basement/No Plumbing
6. If Business/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals — # Water Coolers
If Foodservice: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: W/County/City El Well 0 Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? 01"Yes C3 No
If yes, what type? prr� lt�-" i Utll /2" -42� 61A
PROPERTY INFORMATION REQUIRED: *** IMPORTANT A PLAT OF THE PROIPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: RITE DIRECTIONS (from
Mocksville) TO PROPERTY:
Tax Office PIN* 5-3 f-13 10601
�-X 3a ?-3 3 1 �, 0
Property Address: Road Name tjc�fi I
0 15
City/Zip
If in Subdivision provide information, as follows: V
Name:
Section: Lot #: I;?- J-3 3
This is to certify that the information provided is correct to the best of my knowledge. I understand that any pennit(s) issued hereafter
are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is
falsified or changed. 1, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to
the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County
and owned by 4 &1� lytia. to conduct all testing procedures
as necessary to determine the site suitability.
DATE 10Z ALI I SIGNATURE
Revised DCHD (06-96)
gmsawn N m0cr Seal Or Stamp My commission exprros y OEPUiY • A5S151a14I
WHIP -0_ WILL
A LAND & CATTLE CO
172 Pg- 122
S 8j•50'31' E —y i
940,67
N -- —
♦N
LOT #31 a• Ns
AREA = 5.681 ACRES
WHIP—O—WILL
A LAND & C F
E � D.B. 17.} CATTLE CO. ag.
N b�•3a 9� P
(PLAT BK. 6P9 434 68)
�0:,T #32 9,53. E
N 22'28'51' 2 60 ACRES p1 332•�� r
a so
E No,
s
LT 34
1� w
p: 7 3�g5. E 0
AREA = 5.193 ACRES two
o_ 6k5'a �r
JI-
"�S w
LOT #33 , m
\ pQ� AREA = 5.005 ACRES b �
Z POND
S 2(
>' •2�, a
y�°o.
4 h
!S
!.2 _ 162.99
0
ti 0
27.65
•s4 y �--S 89*27'3 ' N S 33.34'5
y; �9 1�
.h / ��•a 40 AC2FS LN'f pNA v ! 29.62
ati
s F N BRA.ATOUS W Y
n
�QT . X26 . .
a - jkREA d 5.029 ACRES M e . ^4ru
WHIP -0—
A WILL ,.
D ND do
TRAIL
CA77LE Co
I�
CIO,
>9
Of
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & x rc-
. I I A P L 11 W M
Davie County Health Department
Environmental Health Section JAN -9.—
V"
%, P. 0. Box 848
Mocksville, NC 27028 L -----------------------
(704) 634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
ALL THE REQUIRED INFO ROVIDED.
J�MATION IS P 1 9
1. 'Name to be Billed Arrl�contact Person
7
Mailing Address Home Phone 4
City/State/Zip 1 0- .2 Business Phone 0
2. Name on Permit/ATC if Different than Above
Mailing Address
City/State/Zip
3. Application For: X Site Evaluation El Improvement Permit & ATC
4.. System to Serve: House C3 Mobile Home El Business El Industry
5. If Residence: # People # Be-drqoms ' :I-- —
D Dishwasher 0 Garbage Disposal El Washing Machine El Basement/Plumbing
6. If Business/Other: !,��eciify ty e # People
23,
# Commodes # Showers # Urinals
If Foodservice: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: Y'County/City El Well
El Both
0 Other
# Bathrooms
El Basement/No Plumbing
# Sinks,
# Water Coolers
8. Do you anticipate rdditions or expansions of the facility this system is intended to s rve?
If yes, what type?
PROPERTYINFORMA
Property Dimensions:
TaxOfficePIN:#
El Community
El Ye s X N o
IMPORTANT *** A PLAT OF THE PROPERTY MUST bL
SUBMITTED WITH THIS APPLICATION.
Property Address: Road Name e -r -u S 11414,14 -
City/Zip 92281
If in Subdivision provide information, as follows:
Name: (0- -71 Jt -
V44 -S iz-jk:�s u/ kd,�- 81, le
Section: i't Aeaoss Lot #:
WRITE DIRECTIONS (from
Mocksville) TO PROPERTY:
t t
1A RrE-11 oil, 0, I'LA
This is 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 in this application is
falsified or changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to
the Authorized Representative of the Davie County
I I _ I O—N i
and owhed by
as ne . cessary toldetermi e the site suitability.
DATE SIGNATURE
Revised DCHD (06-96)
to enter upon above described property located in Davie County
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION__J_ LOI�,�
Soil/Site Evaluation
APPLICANT'S NAME Z11,
PROPOSED FACILITY
SUBDIVISION
DATE EVALUATED _/ —1
r
PROPERTY SIZE - -T—
ROAD NAME
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS
1
2
4 5 6 7
Landscape position
I-
L,
Slope %
270
HORIZON I DEPTH
Texture group
Cl
0A_
Consistence
wssw
Structure
Mineralogy
HORIZON 11 DEPTH
Texture group
a_
0
+,�DD
Consistence
Structure
Mineralogy
HORIZON III DEPTH
7 -
Texture group
P
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
ri _"� � . 1 '' 7;7
LONG-TERM ACCEPTANCE RATE
C2'L I �.' � 1'� -
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS: (alwrs-'
DCHD(01-90)
EVALUATION BY: Z!
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 clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam
SC - Sandy clay SIC - Silty clay C - Clay
CONSISTENCE
Moist
VFR - Very friable FR - Friable FI - Finn VFI - Very firm 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
SC - 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
M
0
MEMO
MOWN
NONE
MEME
NONE
NONE
soon
0
MEMEMN
EMMEME
MEMEME
MENNEN
VnEMEM
Libbsomm
MEMNON
MENNEN
MENNEN
LINEMEN
LINEMEN
KEEMPEN
mrarmomm
MUMMER
No
ME
on
ME
M
MENSUME
SEEM ME
MEMEMEME
MEMEMEME
NEEMMENE
EMMEMEME
OMMEMMOM
MEMMEMEN
MEMMUME
MEMO No
MEMEMMEM
MEMEMEME
EMEMMMEM
EMEMOMEN
MMENOMME
MEMMEMME
MEMMUME
MEMO ME
MEMEMMEM
0
ANNE
MMEN
NONE
SOON
EMME
OMEN
MMEM
MOEN
OMEN
M
MMEMMEM
MEMEMNE
MEMMEME
MEMMEME
MEMMEEM
MMEMMOM
MEMSEME
EMEMEME
MEMMENE
MEMEMEM
ONENESS
MEMEMME
MEMEMEN
MEMMEEM
EMEMEME
MENMEME
MEMMEME
MEMMEMM
MEEMMEM
SOMEONE
MEMMEME
MEMEMEM
MEMEMEN
MEMEMEM
MENEFAM
Emmumm
EmErims
MMMrAMM
SEE
mom
MEN
NEE
mom
mom
MEN
mom
NEE
mom
A A IP
PPLICATION FOR SITE EVALUATIONAMPROVEMENT PE -&=ATC'�%
Davie County Health Department
Environmental Health Section
�4
P. 0. Box 848 Al 9
Mocksville, NC 27028
(704) 634-8760
0-1 1
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCES
ALL THE REQUIRED INF ION IS PROVIDED.
I . Na I me to be Billed Idl, o -4-J, it 6A. d q- P-4'-:/Icontact Person 2t;e
Mailing Address ZZ 44J 4-0 HomePhone
City/State/Zip 1A 1 0,2 X Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For:
4. System to Serve:
5
6.
Site Evaluation
House Q Mobile Home
City/State/Zip
0 Improvement Permit & ATC
0 Business El Industry
If Residence: # People
4) # Bedrqoms
A -,t -M " -117-"��
0 Dishwasher 0 Garbage Disposal 0 Washing Machine 0 Basement/Plumbing
m S'--8ecify t I
If,Business/Othe vve # People
AP
# Commodes # Showers # Urinals
If Foodservice: # Seats Estimated Water Usage (gallons per day)
0 Both
El Other
# Bathrooms
D Basement/No nbing
# Sinks
# Water Coolers
7. Type of water supply: County/City El Well 0 Community
8. Do you anticipate rdditions or expansions of the facility this system is intended to s rve? El Yes No
If yes, what type?
IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
PROPERTY
Property Dimensions: —7—Z;, tp-- V, WRITE DIRECTIONS (from
I Mocksville) TO PROPERTY -
Tax Office PIN:# ('-40(20 -00 - � 00'::� - I U - -
I ' - " 1'aS: 6 0 -
Property Address: Road Name IA—f 14 -- I C' -M
5, f
City/Zip a(017 0
1, T—Hn:,je., �1 U
If in Subdivision provide information, as follows: "T -
Name:
2-rS 11 lry�A!! j,
ai4—f U/ F46�-- t -s' C-'
Section: Li Aecuyss Em Lot #: 14�
-AJ D A
This is 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 in this application is
falsified or changed. I, also, understand that I am responsible for al I charges incurred from this application. I, hereby, give consent to
the Authorized Representative of the Davie County Health Pipartment to enter upon above described property located in Davie County
and owhed by '6. to conduct all testing procedures
as necessary toldetermi e the site suitability.
SIGNATURE
DATE
Revised DCHD (06-96)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTIoN___L_ LOT
Soil/Site Evaluation
APPLICANT'S NAME e4�Zl;a — Z?_ - /
PROPOSED FACILITY
SUBDIVISION
Water Supply: On -Site Well
Community
Evaluation By: Auger Boring Pit
DATE EVALUATED
PROPERTY SIZE
ROAD NAME �=�r
Public 1___'
Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
'f
Texture group
Consistence
Structure
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: &��
LONG-TERM ACCEPTANCE RATE: 1
REMARKS:
LEGEND
DCHD(01-90)
Landscane Position
EVALUATION BY: 1t2
OTHER(S) PRESENT:
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 clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam
SC - Sandy clay SIC - Silty clay C - Clay
CONSISTENCE
Moist
VFR - Very friable FR - Friable FI - Finn VFI - Very firm 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
SC - 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
MEMNON SEEMEM EMENEE MEMMEM MENEEM
mommoommommommomm
N
0
so
ME
ME