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158 South Hemingway Court Lot 30Davie County, NC Tax Parcel Report Tuesday, November 29, 2016 WAKNING: 'DIMS 1S NUT A SURVEY Parcel Information Parcel Number: H806OA0030 Township: Shady Grove NCPIN Number: 5789142140 Municipality: Account Number: 82515717 Census Tract: 37059-804 Listed Owner 1: HESTER BRADLEY D Voting Precinct: EAST SHADY GROVE Mailing Address 1: 158 SOUTH HEMMINGWAY COURT Planning Jurisdiction: Davie County City: ADVANCE Zoning Class: DAVIE COUNTY R -A State: NC Zoning Overlay: Zip Code: 27006-7049 Voluntary Ag. District: No Legal Description: LOT 30 COVINGTON CREEK PHASE TWO Fire Response District: ADVANCE Assessed Acreage: 0.66 Elementary School Zone: SHADY GROVE Deed Date: 11/2000 Middle School Zone: WILLIAM ELLIS Deed Book / Page: 003510449 Soil Types: WeB,PcB2 Plat Book: 0007 Flood Zone: Plat Page: 139 Watershed Overlay: DAVIE COUNTY Building Value: Outbuilding 8r Extra Freatures Value: Land Value: Total Market Value: Total Assessed Value: F—O-1 Ali data Is provided as Is without warranty or guarantee of any Idnd either expressed or implied Including but not limited to the Davie County, implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless theCounty of Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due toNC or arising out of the use or inability to use the GIS data provided by this website. • DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 - I A (336)753-6780 / Fax # (336)753-1680 11 Account #: 990003588 Billed To: Brad Hester Reference Name: REPAIR PERMIT Proposed Facility: Residential -Repair REPAIR OPERATION PERMIT Tax PIN/EH #: 5789 -14 -2140 -REPAIR Subdivision Info: Covington Creek Lot # 30 Location/Address '..'158 S. Hemingway Court -27006 Property; Size::, 0.692 Acre ATC jgW; Tlie ssuance of this Operation Permit shall indicate the system described on the ATC has been installed in compliance with Article 11 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. 1System Type: S.T. Manufacturer f XIS 1 ? Tank Date A140Tank Size Pump Tank Size System Installed By: Cl H. Specialist: ate: GPS Coordinate: 166, Ea (� a �t asc - erni � DCHD 11/06 (Revised) n .. DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 REPAIR IMPROVEMENT PERMIT AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990003588 Tax PINfEH #: 5789 -14 -2140 -REPAIR Billed To: Brad Hester Subdivision info: Covington Creek Lot # 30 Reference Name: REPAIR PERMIT LocationiAddress: 158 S. Hemingway Court -27006 Proposed Facility: Residential -Repair Property Size: 0.692 Acre A * "1'l; ffhiA7 A3 s W Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS IP/ AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use chance. ;, Residential Specifications: # Bedrooms # Bathrooms? # People I/ Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size Type of Water Supply: igCounty/City, ❑Well ❑Community Well System Specifications: Design Wastewater Flow (GPD):Tank SizeeA1,6"vGAL. Pump Tank GAL. K a Trench Width Max. Trench Depth Rock Depth Linear Ft.J/J ,`7�,�,�, Site Modifications/Conditions/Other: V`r du, " . Contact the Davie County Environmental Health Section for final inspection of this system between 8:30 — 9:30a.m. on the day of installation. Telephone # (336)753-6780. f -------------- I Environmental Health S DCHD 11/06 (Revised) Date: 2 l� _7Nun '1a30 DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) NAME S PHONE NUMBER ADDRESS �SUBDIVISION NAME &( K� //-- / / j /� /IA, I LOT # 3d DIRECTIONS TO SITE 61f 4 114 DN�a st1'(�v V 90 / A-SQIQX 76 ��10N Ze %Iva hA/ ('��ek- V -1 � DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER^`— / l"� I the't"Al'i TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED TYPE WATAull R SUPPLY QU _ SPECIFY PROBLEM OCCURRINGklndga(16J� Atf a a (y%,J qi %o ano/�iill.T-Jj` n DATE REQUESTED NFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. 1193 PPS�— ttee's'r DAVIE COUNTY HEALTH DEPARTMENT �. ame:; �`t'`.' v'�,r �`a�'w '" Environmental Health Section PROPERTY INFORMATION P.O. Box 848 r Directions to property: m: `:'�3 ✓/'-1 `:r�4ocksville; NC 27028 Subdivision Name: Phone #: 336-751-8760 AUTHORIZATION FOR Section: Z. Lot: y WASTEWATERN:# s SYSTEM CONSTRUCTION Tax Office PIN: AUTHORIZATION NO: 2 A Road NameAl l ji)gII ,4 c **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 Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section.] 900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION x,?�'r� }1✓ J / i` 'Ga7 + IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS :57# BATHS ca # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPEE� # PEOPLE # PEOPLF/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY ( DESIGN WASTEWATER FLOW (GPD)" NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH . V) ROCK DEPTH LINEAR FT. A.) REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT`* J r'v6' 4;�e I "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)75.1-8760. OPERATION PERMIT SYSTEM INSTALLED BY: AUTHORIZATION 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 11 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 07/02 (Revised) � �.� -7 72 Account #: 990001299 Billed To: Con Shelton Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 7 7P _ Ile, Tax PIN/EH #: 5789-14-2140 Subdivision Info: Covington Ck Lot # 30 Location/Address: HEMINGWAY COURT -27006' Property Size: see map AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System+Construction MUST 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 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATEA CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: aze Date: 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 11 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. Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: y_ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION P.O. Box 848 A Directions to property:>r� `,o•'.,'� _. rMocicsville, NC 27028 Subdivision Name:r",,"'x R��+ Phone #: 336-751-8760 `. Section:_ Lot:,,, r'Y"f �• AUTHORIZATION FOR WASTEWATER Office Tax Oe PIN: SYSTEM CONSTRUCTION -— THORIZATIO $ - AU N NO: 1 5 A Road Name ) ,. 'c, �, d Zip: ,/ **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 Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article. I 1 of 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. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) v NEW SITE REPAIR SITE 1. SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH DEPTH ROCK D J LINEAR FT./ OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: I q_5�1 IMPROVEMENT PERMIT LAYOUT " ""-*+�•»•...M,M. �. 8.T .. 70 00 "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. Perm�ttee's. r' DAVIE COUNTY HEALTH DEPARTMENT Name: x. �i'%j r err`'' l�"' Environmental Health Section PROPERTY INFORMATION �� P.O. Box 848 Directions toproperty:- E r"' �- J �+� l`f Mocksville, NC�27028', Subdivision Name: �� "�✓. Jr: "" ' .r rP Y Phone #: 336-751-8760 Section: Lot: AUTHORIZATION FOR ff} WASTEWATER Tax Office PIN:# - SYSTEM CONSTRUCTION ,�% AUTHORIZATION NO: 15 A Road Name// �' 1,> iI iw Zip: ��_ **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 Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article I I of 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. ENVIRONM NTAL HEALTH SPECIALIST DATE ISSUED i RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS ` GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT / # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY ( v DESIGN WASTEWATER FLOW (GPD) �b NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH OK ROCK DEPTH !rte! LINEAR FT. 7fr REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT y �, w f AG % cJ7' X"Ve, �. yid "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: AUTHORIZATION 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 11 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 0I102 (Revised) ,,� - X772 Account #: 990001299 Billed To: Con Shelton Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street ��1,6,6,,'/�S 7e -r MockrAlle, NC 27028 (336)751-8760 Tax PIN/EH #: 5789-14-2140 Subdivision Info: Covington Ck Lot # 30 Location/Address: HEMINGWAY COURT -27006 Property Size: see map AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST 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 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATEA CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: 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 11 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. F Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: -; l — DAVIE COUNTY HEALTH DEPARTMENT ` Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001299 Tax PIN/EH #: 5789-14-2140 Billed To: Con Shelton Subdivision Info: Covington Ck$.Lot # 30 Reference Name: Location/Address: HEMINGWAY COURT -27006 Proposed Facility: Residence N Property Size: see map ATC Number: 2629 **NOTE** This Improvement/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 #People #Bedrooms :� #Baths Dishwasher: � Garbage Disposal Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial 13�Waste: Lot Size d �pC Type Water Supply �� Design Wastewater Flow (GPD) —<✓iv Site: Newer Repair ❑ System Specifications: Tank Size/,MGAL. Pump Tank [VQ= Required Site Modifications/Conditions: GAL. Trench Width ,3&� � Rock Depthe�L Linear Ft.,-jZ0 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.m. t j k 3p p.m. on the day of installation. Telephone # is (336)751-8760.**** 0 Environmental Health Specialist's Signature: _ / Y� Date: AU� DCHD 05/99 (Revised) APPUCATION FOR SITE EVAUJAT10N/IMPROVEMENT PERM do ATC E ` Davie County Health Department [ [ OWE Envftvnmenfarf MMIM Secbfon D �� P.O. Boa 818/210 Hospital Street Moaksville, HC 27026 OCT 2 4 (336)751-9760 ***DWCRTU"** THIS APPLICATION C711t M BE PRO=VSBD UNLESS ALL TAE IN>roMUZON IS PROVIDED. 1Refer to theJ 1TIOH BULLZTIN for instructions. / i. ltame to be Billed S f� l % _ _ T - - J o Contact Person— Wilinq address LZ S % U no" "Was % S/ - L Z SR city/state/22s, 1')7-- /� Business Whone o U Z. Ilan on iterait/h=C It Different than Above Waiting Address t••ity/stats/sip'" s. Applicationfors Amite Evalnatioa rovaomt Permit/ATC a Both 4. system to services Ouse 13 Mobile Home 13 Business O industry 0 Other s. It Residence: s people _ I Bedrooms 3 e Bathrooms ishwasher With; sge Disposal d -M CigW Machine O saaeaant/01iabing O saeeaentmo )dumbing 6. tf Business/tadustsy/others specify type ; people E sinks # commodes i showers i Urinals I dater Coolers Ir 300D8ERVICE: # Seats Estimated Water Usage tgailons per day) 7. Type of Mater supply: WtZuin'ty/City n Well 0 Community s. Do you anticipate additions or expansions of the facility this system Is intended to serve? 0 Yes If yes, what type? ***1UP0RTANP** CUENTS MIISTC OMPLMTHE REQUIRED PROPERTY INFORMATION REQUMED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Properly Dimensions: 12 X J� (• 7o A�-->WRITE DIRECTIONS (from Moclovllle) to PROPERTY: Tax Office PIN: A S '-7 Y7 / j— '214 0 Property Address: Road Name City/zip q 1.a — c �7 Gid (� If in a Subdivision provide Information, a follows: Name: Section: ]a =+iJL Blocks Lot: Date Property Flagged: This Is to certify that the lubrmation provided Is correct to the bat of my knowledge. I understand that any permits) 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 lncarred from this application. 1, hereby, give consent to the Authorized Representative of the Davie Conn Health Department to enter upon above described property located In Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE / b /Z �V SIGNATURE C THIS AREA MAY BE USED FOR DRAWING YOUR STTE PLAN (Include sit of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) jDaft(s): Client Notification Date: Account No. / Invoice No. 0 �� Cz t � �.4- 1 � 9 1 7 v /Zo N N Y� p f♦ z: Revised DCHD (07/99) jDaft(s): Client Notification Date: Account No. / Invoice No. 0 �� Cz t � �.4- 1 � 9 1 7 v APPLICATION FOR SITE EVALUATICNAMPROVEMENT PERMIT Davie County Health Department Environmental Health Section P.O. Box 848 Mocksville, =NC 27028 (704) 634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL _� 1 THE RE UIRED INFORMATION IS PROVIDED. Name to be Billet • 1y� r,^ e- S Contact Person / �� -� t►rP1 Mailing Address ?1) At))e ;)-361) Home Phone City/State/Zip UaiJ Ce- 2700(3 Business Phone 18/3-1391 ' 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For:ite Evaluation [ l Improvement Permit & ATC C [ J Both 4. System to Serve: [ ] House [ ] Mobile Home [ ] Business [ ] Industry [ ] Other % 0+ sual yi.Sio.J 5. If Residence: # People # Bedrooms # Bathrooms [ ] Dishwasher [ ] Garbage Disposal [ ] Washing Machine [ J Basement/Plumbing [ ] 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: County/City [ ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes Hlqo If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***'A FLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions. 1- —.t 4,8 QC: , ot-c-e WRITE DIRECTIONS (from Mocksville) TO PROPERTY: Tax Office PIN: # 789 - =sh id 1, L - —<=1dy u C e Property Address: Road Dame g0 j O�.mr , / m '► — , g 'S J S'Iot' o f City/Zip Adt) • 2,7a -o ; _G1 Ca'n cS_� r,m ��► e �' i� U�'t'S If in Subdivision provide information, as follows: Name: bl1/n4dat] Pee -k— a&DQSzd ; r Section: 1 Lot #: D This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter ar subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorize ve of the Davie County Health Department to enter upon above described property located in Davie County and owne ,,,1 Revised DCHD (06-96) SIGNA all testing procSoures as necessary to determine the site suitability. I PINS AI;r•1 11111 Lir: II,rb )-01, 14611VIN6 !011; SI [F PIAN: " DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT- Soil/Site Evaluation APPLICANT'S NAME d� � `� DATE EVALUATED e' PROPOSED FACILITY � /„ PROPERTY SIZE 3�l.AC SUBDIVISION COL/ ,e,,4 SST W &e& ROAD NAME ZE22 Z Water Supply: On -Site Well Community Public t_� Evaluation By: Auger Boring Pit ICut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % 41 HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence r Structure ✓L 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: REMARKS: , <e -se 777h a &A,-- 4b /y AV LEGEND DCHD (01-90) EVALUATION BY: /& // OTHER(S) PRESENT: 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 - 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