131 Cooks Trail 4B" APPLICATION FOR SITE EVALUATIONMVROVEMENT PERMI O M a
Davie County Health Department D V LS D
Environmental Health Section
P. O. Box 848 JUL 20
Mocksville; NC 27028
(704) 634-8760
ENVIRONMENTAL HEALTH
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED4414171398DAVIE COUNTY
Q
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be BilledL// 'y Contact Person �v�U
Mailing Address /'0606 W 7 Home Phone
City/State/Zip CQO (ee ntvb NX/ Z704 Business Phone d o 5 S l
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For: ❑ Site Evaluation
4. System to Serve:
5. If Residence:
M115ishwasher
6. If Business/Other:
# Commodes _
If Foodservice:
❑ House ❑ Mobile Home
# People
❑ Garbage Disposal
Specify type _
# Showers
7. Type of water supply:
_ City/State/Zip
❑ Improvement Permit & ATC O' Both
❑ Business ✓✓��❑ Industry ❑ Other
# Bedrooms `J # Bathrooms 12—
C4' Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
# People # Sinks
# Urinals
# Seats Estimated Water Usage (gallons per day)
❑ County/City Well
# Water Coolers
❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes l" No
If yes, what type?
*** IMPORTANT
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: 5 0'�1 WRITE DIRECTIONS (from
1 Mocksville) TO PROPERTY:
Tax Office PIN: # ��� �Z�� 1
rn 1
Property Address: Road Name
City/zip
If in Subdivision provide information, as follows: L 1
1
Name: 1
1
Section: Lot #: 1
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
and owned by
as necessary todeterminethe site suitability..
—/
DATE —2,d —qU SIGNATURE
Revised DCHD (06-96)
above described property located in Davie County
conduct all testing procedures
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159.42'
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133.21'
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Mare Smith Link
DB 61 O PG 38
N 02"43'20"E 94,?.6.
IRS 221.50'
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3 1.5 Acres Portion
v I of Parcel 1 Zoned RIA '_ $
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IRS 221.50'
P
428.52'
Part of Tax Lot 16
Parcel 1
Total Area: 5.001 Acres +/-
Note: 3.5 Acres of Parcel 1 Zoned Industi
813.83' Total S 02"43'20"W
592.33'
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,t
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P -
Centerline Proposed 60' Access Easement c
IRS N
Part of Tax Lot 16
Parcel 2
Total Area: 5.098 Acres
N 02'43'20"E 337.38' IRS
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IRS
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a
Part of Tax Lot
16.
3
Parcel 3ly5
Total Area: 5.027 Acres
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s'o' 60,
Part of Tax Lot 16
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Parcel 4
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IRS �
To,'al Area: 5.//022 +/-
IRS
Acres
115.00'
S 83°46'5511W
N 03°44'15"E 669.40'
259.51'/S. y IRS
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oo.
409.89'
Tax Lot 16
Tar Mao M-5
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LoT!�d
Soil/Site Evaluation
APPLICANT'S NAME 2127 '\
PROPOSED FACILITY A
ll
SUBDIVISION'
DATE EVALUATED16i!?l
PROPERTY SIZE 2� C
ROAD NAMEt '
Water Supply: On -Site Well Community Publicy
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 1 5 6 1 .7
Landscape position L
Slo e %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON ll DEPTH
Texture groupt✓'
Consistence r. i
Structure
Mineralogy
HORIZON IH 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:
REMARKS:
DCHD(0I-90)
EVALUATION BY:
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
tructure
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
ii