116 Cooks Trail Lot 7B1APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT a
Davie County Health Department FE=SEP231(998 VEnvironmenfa/Health Section
P.O. Bos 848/210 Hospital StreetMocksville, NC 27028
1336)751-8760
--1 -- DAVIEI:uunn
***IIIPORTANT*+• THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL REQUIRED
INFORMATION IS PROVIDED. nRefer to the INFORMATION BULLETIN for instructions
I. Name to be Billed UQT /`, •S�J� l ��•yl C. /i Contact Person 11 ''60 F i
Nailing Address 2 13' '73P acme Phonecp 11gG�L1' /f��iy
City/state/ZIP _(/iOr' /%%c /V C N(h ILI Business Phone 33 1,s '
2. Name on Permit/ATC if Different than Above
Nailing Address City/State/Zip
3. Application For: ❑ Site Evaluation 0 Improvement Permit/ATC�(
l Both
4. system to service: ❑ House Mobile Home '❑ Business ❑ Industry ❑ Other
5. If Residence: i People 4_ # Bedrooms 3 t Bathrooms oZ.
0 Dishwasher 0 Garbage Disposal 4fWashing Machine 11 Basement/Plumbing D Basement/No Plumbing
6. If Business/Industry/other: Specify type / People i sinks
i Commodes I showers % Urinals # Nater Coolers
IF FOODSERVICE: / Seats Estimated Nater Usage (gallons per day)
7. Type of water supply: ❑ County/City ❑ well
❑ Community
s. Do You anticipate additions or expansions of the facility, this System is Intended to serve! ❑ Yes ,grNo
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"*"IMPORTA "CLIENTS DIUST CO3IPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Elther a P jL�ATor SITE PLAN DIUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: Y 2 YA C
Tax Office PIN: g>� R 21 �� 00 WRITE DIRECTIONS (from Mocksville) to PROPERTY:
rj
Property Address: Road Name r Inn '3,1M
t. I p
r City/Zip V` 1 M Zg
If in a Subdivision provide information, as follows:
Name:
Section: Block: Let:
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permll(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 lam responsiblejor all charges incurredjrom
this application. [,hereby, give consent to the Authorized Representative of the Davie only Health part ent
to enter upon above described property located in Davie County and owned by QQ �� h-yC��
to conduct all testing procedures
as necessary to determine the site suit ility.
DATE `C- AL3 / p SIGNATURE
Ti L S AREA MAY BE USED FOR DRAWING YOUR SITE PLAN:
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Allp ieetiow No. a( k
Invoice No. A
Revised DCHD (07/98)
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17.88' Axle, Found
813.83' Total S 02°43'20"yy "Buggy'
P 592.33' IRS N
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�— Centerline Proposed 60' Access Easement See Call Table
— IRS N 02°43'20"E 314.5f' IRS /
of Tax Lot '1 6 N 65°I )'45"W ,/ a /
Parcel 2 64. S9' /10/ /
,ea: 5.09b Acres
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Sheet 2 of 2
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'79/
DAVIE COUNTY HEALTH DEPARTMENT
"Environmental Health Section '' SECTION IAT
Soil/Site Evaluation
APPLICANT'S NAME DATE EVALUATED Zn I ��
PROPOSED FACILITY Y�l • u�rnl� PROPERTY SIZE
SUBDIVISION ROAD NAME " NCi1 YAGn S�1CJ�+
Water Supply:. On -Site Well Community Public
Evaluation By: Auger BoringPit Cut
I
SITE CLASSIFICATION: 1/5 EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: o.4. 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 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
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely'firm
We4 .,
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
ocHD(01-%)
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SITE CLASSIFICATION: 1/5 EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: o.4. 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 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
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely'firm
We4 .,
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
ocHD(01-%)