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AUi Hod ATION NO 7 g - DAVIE` OUNTY HEALTH DEPARTMENT f
;Environmental Health Section PROPERTY INFORMATION
xefmuice a
Dirffec4ons to propel
**NOTE*, This 16
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' ENVIROI3ITAL H
MENTAm
P"altaccS
ovementpemdt DOES NOT.'auihorize,the constn
UZATION FOR WASTEWATER SYSTEM CO
oa/installat ou of it 4stem or Nie issuance of a Buil
,rticle 11 of G.&P apter lMk Wastewater Syste
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ITH�SPECIALIST ;:, DA I UED
RESIDENTIAL SPECIFICATION:.BUB.DING.;TYPE- IV N # BEDROOMS -w� # BATHS d—'_ # OCCUPANTS !7 GARBAGE. DISPOSAL: Yes d(�IyJ 7
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APPLICATION FOR SITE EVALUATION/IMPROVEMIM PERMR & AT
Davie County Health Department
VSEP
Environmenta/Health Section
P.O. Box 848/210 Hospital Street 1998Mocksville, NC 27028(336)751-8760 Te� NFAI
•**IwortTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed LJ[)QT%l .s�;�]��� . Contact Person /1 6 f r -
Hailing Address /�2e2 )12V V3 IF Boma Phone— -331,4 �g,q- j qyq
city/state/zip ( (�C L F j�� K1 49 1 [� Business Phone -331's
2. Name on Permit/ATC if Different than Above
Hailing Address City/State/zip
3. Application For: ❑ site Evaluation ❑ Improvement Permit/ATC Both
!. System to service: ❑ House I Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People 4 # Bedrooms .3 # Bathrooms 01.
11 Dishwasher 0 Garbage Disposal •irWashing Machine n Basement/Plumbing 0 Basement/No Plumbing
6. If Business/Industry/Other: Specify type # People # sinks
# Commodes # showers # Urinals = # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: ❑ County/City ❑ Well
❑ Community
a. Do you anticipate additions or expansions of the facility this system is intended to serve! ❑ Yes ,AN0
***IMPORTA** CLIENTS A/USTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN AIUST RESUR.1111TED by the client with THIS APPLICATION.
Property Dimensions: i 2 ey
57
Tax Office PDN: # �
y.S 9 a 18 l oo WRITE D CTIONS (from Mocksville) to PROPERTY:
Property Address: Road Name Q p Y
City/zip 9'7D a
If in a Subdivision provide information, as follows:
Name: 22
Section: Block: Lot: 'J ,
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 1, alto, understand that lam responsiblejor all charges incurred from
this application. 1, hereby, give consent to the Authorized Representative of the Davie,�ounly Health epartment
to enter upon above described property located in Davie County and owned by nC P C �!� .) I rn c r1
to conduct all testing procedures as necessary to determine the site sui ability. 0
DATE I `Z3-9_ SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN:
� No.
Invoice No. /
Revised DCHD (07/98)
Z '� \
S 7.?°51'00"E
17.88' A ale: Fouad
813.83' Total S 02°43'20"W "Buggy'
P 592.33' IRS N
�- L-7 P Te tine 346 91,
K, Centerline Proposed 60' Access Easement See Coll Table IRS
IRS N 02°43'20"E 314.5EIRS /
of Tax Lot -16 N 65°1')'45"W /
Parcell 64.:9'
rea: 5.096 Acres +/- t V°
AIC,k
RS
o� i
' /,v`O• fax Lot 16 �
I Tax Map M-5
'16 _ n/f Roger P. Spillman
7Gr DB 190 O PC 101
P/0 Parcel 7
v Tax Lot 16 N
L f �j o Tax Map M-5 G
j y �A7(0 0 �� `" r,y/ / n/f Roger P. Spillman
DB 190 Q PG 101
`\ 2?0.00' P/0 Parcel 8
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125.O0' , V�UsI�See Ca, TohAccess Ease nt Pk I
83°46'55"W 1 e
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IRS 1201.1
(J, N 83';
Tax Lot 16
Tax Map M-5
n/f Roger P. Spillman CD z Tax i of 16
DB 190 O PG 101 o I Tar M-5
1 n/f Roger P. Spillman
Porrsl 7 ° ; DB 190 ' PC 101
(Area: Acres +/-) 1 v Pu at 8
z a�
w o
0
Cn n
m
ix Lot 16 0, 1 ml
15
931 Acres
PJ�y+tq►� 1 01
1 1
119.22' 1
S 03°56'35"w1/2" EIR
IRS i : Line 1/2" EIR
e
1/2" EIR 1/2" OF N 05 124'05"E 255.67' S 05024'05"W
119.89'
Tie Line
0 19 18 � 17 1 �i I 15 I 14
00 I1
O1 �
,6
"Sallie Acres"
N Sheet 2 of 2 ",Sallie Acres"
a PB 6 O PG 160
E o Sheet 2 of 2
PB 6 O PG 160
6.70' i
:A7r. W
FACTORS
1
2
3 4 1 5" _- 6 7 "
Landscape position
Sloe %
HORIZON I DEPTH . .
p a
Texture group
Consistence
Structure
Mineralogy
HORIZON H DEPTH
Texture groupGk
o
Consistence
Structure
.
Mineralogy;
(
;
HORIZON III. DEPTH
s
Texture group
Consistence(
-
Structure
(9
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
b
LONG-TERM ACCEPTANCE RATE
If :
0
-
SITE CLASSIFICATION:EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: 0 OTHER(S) PRESENT:
REMARKS:
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 Ir -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 `- Firm 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
ME
ME
No
ME
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