160 Wilson Trail Lot 6B,:: octet 05r96 (rtewwe)
1
APPLICATION FOR SITE EVALUATIONAMPROVEMENT
> Davie County Health Department
Environmental Health Section
E O. Box 848
Mocksville, NC 27028
(704) 634-8760
**** ANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
ALL THE REQUIRED INFORMATION IS PROVIDED.
Name to be Billed �jContact Person7�
Mailing Address Po , boy 6 � 0 Home Phone p
City/State/Zip � 0 ""��� ""� a —7014 Business Phone �0 /
2. Name on Permit/ATC if Different than Above
Mailing Address
City/State/Zip-
r9
3. Application For:
❑ Site Evaluation ❑ Improvement Permit & ATC
Both
4. System to Serve:
❑ House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
3
5. If
# People # Bedrooms #
Bathrooms
Residence:
d
❑ Garbage Disposal l3' Washing Machine ❑ Basement/Plumbing ❑
Basement/No Plumbing
Dishwasher
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:
❑ County/City ❑/`T�'ell
❑ Community
8. Do you anticipate
additions or expansions of the facility this system is intended to serve?
13 Yes lyNo
If yes, what type?
*** A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: �ir I WRITE DIRECTIONS (from
Mocksville) TO PROPERTY:
Tax Office PIN: # d7IT5
Property Address: Road Name
City/Zip
If in Subdivision provide information, as follows: 1
1
Name: 1
1
Section: Lot #: 1
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 Health Department to enter upon above described property located in Davie County
IW
and owned by (7 Z �,,�2 ,z�) to conduct all testing procedures
as necessary to determine the site suitability. -
DATE / —2O—qg SIGNATURE
Revised DCHD (06-96)
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259.51' �/S Z IRS 409.89'
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Part of Tax Lot 16
M Parcel 5
Total Area: 5.931 Acres +/-
Part of Tax Lot 16
Parcel 6
Total Area: 6.212 Acres +/-
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Tax Lot 16
Tax Map M-5
n/f Roger P. Spillman
DB 190 O PG 101
Parcel 7
(Area: 8.4 Acres +/-)
119.22'
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Sheet 2 of 2
PB 6 O PG 160
proposed 60• Ac wEasement 226.70'
_ g S 06'54'35' W 1/2" EIR
IRS 361.10' S 06.54'35 "W 8 _ — — — — —
- - - IRS 1729'
IRS60.61' --------------------------
'- --- ----------- ------ - - - -_— - - -- - - - - -- - — -- - - -- - - --
/ - - - - Michaels Rom
�,' / 60' Public R/W 18
a DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT'S NAME
PROPOSED FACILITY
'SUBDIVISION
SECTION LOT
DATE EVALUATED !',e
PROPERTY SIZE f 2 0
ROAD NAME /
Water Supply:
On -Site Well
Community
Public
Evaluation By:
Auger Boring
- Pit
Cut
-
.. •, s�r_�®tee®®
Lei 114 Irks!] 0 11101:4 W 0
met 14111
..:
9071 �JL
SITE CLASSIFICATION; EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: 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
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