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P6973 McClamrock Rd:; + 1•'sy 'S:`�+*�+� i'f iia v9 �,�-� v• :.-s+v. _'e4:^wra2�w�:fa!y�;;,'...,+� .".r'-'+�,�sw.�-• �^.�xy�+,'r.:�^ '�++-�� r•- sr•s^� t --r. l � �' 1. Application/Perry Mailing Address Home Phone APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 2. Name on Permit if Different than Above Business Phone `E-" U/'C-/V 3. Application/Permit for: ❑ General Evaluation R -'Septic Tank Installation 4. System to Serve: House obile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other El Unknown 5. If house, mobile home: Subdivision .516A /fiT & M 9 Section �J 'J Lot # No. of People No. of Bedrooms `3 12 No. of Bathrooms / L ,74 Dwelling Dimensions �© d 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories No. of Showers 7. Type of water supply 8. Property Dimensions ❑ Public No. of Sinks No. of Urinals No. of Water Coolers Water Usage Figures ❑ Private Sewage Disposal Contractor ❑ Basement/Plumbing ❑ Basement/No Plumbing ❑ Washing Machine ❑ Dishwasher ❑ Garbage Disposal 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 13-11-0-- If ho If yes, what type? ❑ Community *NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: L This is to certify that the information provided is correct to the incurred from this pplication. 02. DATE I W-. .11 MRS .0 my know) _ and I understand I am responsible for all charges SIGNATURE !, CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. hL•��� DCHD (12-90) SIGNATURE _ .. 39 Ac. X0:2: _ _ r-• ,r '� Ac 'se k 280...V .a Q7 SAC 54 Qom.3. 52 8 i" ' Z 2 A ) ` 1.09 A' 3A` o �2b 20 a �y 87 30 ,. S R` Q 347 (' NOP rr.. 14 3 65Qc, BAPTIST $ � W0 _ '� �;� E o & 7 5 epWARp " .:fiTABERNACL Y�r sy, Ac ` 6 7 O ` �� h \00 95* u' 281 3 3 X tirrf.4A $.0 F 9 4b 07l1 as 4' 378 5 /: ap'6 2 lq p {I C � Q ry`IV �j]6 .46 AG.) i tg910 j a0 8 4.33 1 8 � #a�' 921,AtS °3 �45 AC. 7.01 s { 4 2 24882' (4 Z) 31 c ss a 61 o w r" . t./5 i 2g5. ` s h.lr n. 9 OIlv ' <1 ''S/ I..r'"- 148 Z250m 1�J0 talc ` ..6.. 2 0 2 ' �r 1 > " ? 'ei. M� .:gil B . 112 -Ac 82 'S '^ 6 1 I °2 °8 ~ y� l*.. 1.01Ac g9 0 d e 24 s 1177 4, \0/Pry_. 17.3�AL� ..' t4dc.Tj p o W 3 �I6D a 253. Niv AC, N SII 16.4AC)�4,09 LP — �/� "1.25 Ac m O B 7. s5 Ac.)26 c �. ° e io O c' • 2 561N -IM03 o N 19� c m 25. A C ti91 78y.� N o (" x ti e ,y 4.3 .raA 4p� DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section • Soil/Site Evaluation NAME DATE EVALUATED——�-2 ADDRESS PROPOSED FACIILTY PROPERTY SIZE l LOCATION OF SITE l� / Water Supply: On -Site Well Community Public '4--' Evaluation By: Auger Boring ._ Pit Cut FACTORS 1 2 3 4 Landscape position L L L Slope % — HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH � Texture groupC� Consistence Structure 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 C ,c SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: DCHD (01-901 EVALUATED 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 -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 ■■ SEEM ■E■■ ■EM■ ■MM■ ■ES■ ■EEM ■ME■ ■E■■ ■■M■ ■ES■ ■SM■ ■■ STATEMENT DAVE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION 210 HOSPITAL STREET P. 0. BOX 665 MOCKSVILLE, NORTH CAROLINA , 27028 (704) 634-5985 December 9, 1992 r Roy Potts P. 0. Box 11 Advance, NC 27006 Site Eval. & Permit 6973 - $100.00 Pa ent Due Within 30 Da s oeTACH Aso a" w °roue cNam roup cA uEo a�at roup �rar*. 12-09-92 (Site Eval. & Permit 6973/Ray Potts 1 $10M ---------+----- ------------------------------------------ 12-09-92 IPAID/Rct. 15669/Check 2339 1 -100.1 ----------------------------------------------------- 7 ------ 1� -----------.-------------------------------- --------------•. I i ----------------------------------------------------------.-., I 1 ---------4{ -----------..--•-----------------------------+------- I ---------------------------------------•---•----•------------- I I •-------------------------------•-------------.------•---------• -----------------------------------------------------------. 1 I -----------------------------------------------•------------• i -------------------------------------------- ------------' I t ----------------------------------------------------f------ I BALANCE DUE - i - 0