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110 Old March Rd Lot 1 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 989900025 Tax PIN/EH#: 5789-76-5851.01 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Sec.1 Lot#1 Reference Name: Dick Anderson Location/Address: Peoples Creek Road 27006 Proposed Facility: Residence Property Size: 3/4 Acre ATC Number. 2214 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 WASTE O U4310N I ALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signatu e: Date: 4 3 gel roo n5 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.�P 17--2-1 go ,p, S sr Septic System Installed By: Environmental Health Specialist's Signature Date: DCHD 05/99(Revised) ,. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900025 Tax PIN/EH M 5789-76-5851.01 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Sec.1 Lot#1 Reference Name: Dick Anderson Location/Address: Peoples Creek Road 27006 Proposed Facility: Residence Property Size: 3/4 Acre ATC Number: 2214 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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 r�0 #People #Bedrooms #Baths Dishwasher: Garbage Disposal: ET Washing Machine: E Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #S eats Industrial Waste: 13Lot Size 15C V-Z20' Type Water Supply T(Design Wastewater Flow(GPD) C� Site: New 0" Repair❑ System Specifications: Tank Size I�iAL. Pump Tank GAL. Trench Width 3t;t Rock Depth 12-" Linear Ft.--51Z1' Other: , 1N5>�.l..t_ �nS�S �ta•C, Required Site Modifications/Conditions: IL61A Ib'IPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISERS)IF 6 K BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this stem between 8:30 to 9:30 a.m.or 1:00 p.m•to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** 0 �o� af MQ/-. ICx� k �,2-" S 1 cx7 Cy Environmental Health Specialist's Signature: Dat DCHD 05/99(Revised) AXT1.I ATION FOR SITE EVALUATION/IMPROVEMENT PERMIT M Davie County Health Department D 55 Environmental Health Section P.O. Box 848 9 ', Mocksville NC 27028 JUN — 8 iM ENVIRpT�NIMPO ANT**** THIS APPLICATION CANNOT BE PROCESSED Nl, YIRON6IENTAI HEALTH A IEECO ALL THE REQUIRED INFORMATION IS PROVIDED,E DAVIECOUNTY 1. Name to be Billed ,f�lG� Q�1lDr2�3 at)a6wi—s.-Z�/C . Contact Person An' Mailing Address c,7-?S- WING- 49 t 1,=Al LA/. Home Phone - 7s 717 City/State/Zip �MQC&S t/le.C.0 . /1�.C ? 70 Z F Business Phone 334 qqS-7a,-7 q 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: f Site Evaluation [ Improvement Permit&ATC ❑ Both 4, System to Serve: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: _ # People # Bedrooms -3 # Bathrooms 1 Dishwasher X Garbage Disposal Washing Machine ❑ 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: X County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes No If yes,what type? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A P.Y.ATORTHE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: R,,47- /OCtIV 6,1V CC.UScU 1 WRITE DIRECTIONS(from Mocksville)TO PROPERTY: Tax Office PIN: # 7 7 - - 6-k •5-/ 1 t /5 8 7V 8801 - -I4W-A) Property Address: Road Name iPT 7-0 1-70VA1VCE City/Zip AO✓AAX,,=. Al. C a 700 G ' I If in Subdivision provide information,as follows: t 1 K AQ Name: FYI A"e Cf-1 won Us I /YI/fFrB Section: Lot #: 1 t GU�.rx�s DAO' 2r. 1 This is to certify that the information provided is correct to the best of my knowledge. I understand that any pen-nit(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 1 am responsible for all charges incurred from this application. 1,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 �_ Q14AI H 00 7-r, to conduct all testing procedures as necessary to determine thesitesuitability. DATE 6 7 SIGNATURE Revised DCHD(06-96) YOU MAY USE THE BACK OF THIS FORM FOR DRAWING DOUR SITE PLAN. - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT—/ Soil/Site Evaluation APPLICANT'S NAME DATE EVALUATED PROPOSED FACILITY PROPERTY SIZE SUBDIVISION IWW ) 7 jV BQ�s ROAD NAME Water Supply: On-Site Well Community Public L1 Evaluation By: Auger Boring Pit 1'.` Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe% HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH T >% Texture group 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 i;TE:j .p i SITE CLASSIFICATION: /� EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: ✓ r T G 69C� LEGIEND 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 DCHD(01-90) SIDNEY F. HOOTS / D.B. 175 Pg. 507 ----- / i' N 33.47'22• E ` 22 _ 231.61 ` / %0lb- 0?0 ----- /' i' I_---- _ �' _- ems, / a�� .• - If tQT #8 A. HOOTS 00 '5 Pg. 504 \\ / Ze \\ / LOy' 7,'� . , / \\ 1` /,'�; ''0 ,�. /,/ _IIII�i ,i �/ /�,' jl L1�T,, �., 6' o i \ 1 / / \ \ ! \ r i' _ f `� \✓ ,i' TJO n \ l \ \\ 80 \\\ \ i i �-��. ti� 09( r` N �� 93\`� \\ / /� \ �\\ \\ \\ \\ 1 \ \ I I �'J �� / i r l / l I i 11 j i 1 1 6 i \ //' / mow! \ \ � \ 1 \ \ \i I r / i � / /! � I 15 LOT #5/ .56 el 0cu N r 7. \lsqOZ � "1f1�/ ,/ / \\ ' ' r 'f�i� i' �// / /� i l i / LOT ( I LOT f1 aj _�- ^/''� 1t�o�X�7,0�',�,57o,Nr 33 O / LOTf17 i' l6�,2 i' / �i - r i i i� // 1.0 150 T —LOT- 2#------%/ / jQ. sIo►t> n i' i/ i i/ / i/' i//� /�-- ` \ LOT / /' / ,�/ j i,/ \ r `��— 'i "I 1 _- f / f/��T 0 LOT\ \ \#9 � I I // ,� �, \ / 1 r r I I I I I I I I / � T I I I If7 �, t:11 / / 14 / 1 ►1 \ I t r I I I I / ��'� — I I kn I / eu \ n �� m '\�\N ( I N I / N \ I nil o / / \ / I I I \I 1 \ I I /�- \ I 1 1 ME t6T #23A i/ / i i I I \ \� 1 r 1 i i r LOT #1'a\ / I / III I N LOT �` 130 / qq LV I /�// ./ ��/ �/ // / /) / 1/ , //—� \\\ \\\\ 140-V-- JAI 'w /' �� //-!�/ NOT \ / t. ALL LOTS ARE SUBJECT TO DAVIE COUNTY HEALTH DEPARTMENT STANDARDS. 2. ROADS ARE TO BE BUILT TO NCDOT ST BEING A PUBLIC ROAD WITH A 60' RIGHT OF-WAY