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110 S March Ferry Rd Lot 26 DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 989900025 Tax PIN/EH#: 5789-76-585126 Billed To: Dick Anderson Construction Subdivision Info: 609MO99- Lot#26 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27006 Proposed Facility: Residence Property Size: 3/4 Acre 64 **N(R *'Thi bfmprovemment/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: 2r—""Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply e— Design Wastewater Flow(GPD)�M Site: New Repair❑ System Specifications: Tank Siz��GAL. Pump Tank GAL. Trench Width��(Rock Deptl}4 k "Linear Ft / Other: Required Site Modifications/Conditions: 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.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** Y ��' - _ 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 Account #: 989900025 Tax PIN/EH#: 5789-76-5851.26 Billed To: Dick Anderson Construction Subdivision Info. �� Lot#26 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27006 Proposed Facility: Residence Property Size: 3/4 Acre ATC Number. 2364 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 WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �o �Z WJ-",Date: GAS'•�� - 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 er e given P � . J f a o el _S I� r Septic System Installed By: z744 01 Environmental Health Specialist's Signature: r4Z Date: DCHD 05/99(Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMI p Y Davie County Health Department Environmental Health Section P.O.Box 848 _ 8 Mocksville NC 27028 JW ( 3 6 j751-8760 Im ENVIRONMENTAL HEALTH ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESS . SVIE COUNTY ALL THE/REQUIRED 1-/�/INFORMATION IS PROVIDED. 1. Name to be Billed / iVI�C/28 O.(�C.EL!/S%. C . Contact Person -/��G� /-{n tJO $D41 Mailing Address c,? S W1 Al G- 44 t/4EAl L Al, Home Phone��q/�.�' 7s 7 F City/State/Zip �MQ01--5 ✓lc.0 C . AL C 2 70 a P Business Phone 3-34 r1 Rg-7027q 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: Site Evaluation 9 Improvement Permit&ATC ❑ Both 4, System to Serve: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms -3 # Bathrooms Dishwasher Garbage Disposal X 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: 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 PY.AZMTHE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: RAT 00eqAl E/Y CC.y.Scn i WRITE DIRECTIONS(from i Mocksville)TO PROPERTY: Tax Office PIN: # 4;-7 9 - .7 - % i i /S8 w 8,0 - �z°C•e•(I Property Address: Road Name P�OPC&A CiP� K /,0_ i i /2T 7-0 40VAIVC.,—= City/Zip AO✓AAX,_ Al C cq 70 0 G i i T&vwL f=T p v i If in Subdivision provide information,as follows: i 1 K Name: nA'Q CH won zs i i mics Section: Lot #: i GtJcxx�s DiY �2r-. 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. 1,hereby,give consent to the Authorized Representative of the/ HD'avie' y County Health Department to enter upon above described property located in Davie Count H and owned by LIDf��I! W. CSO LS to conduct all testing procedures as necessary to determine thesitesuitability. �7 DATE 6 (9 ^ 7 SIGNATURE Revised DCHD(06-96) JOU AIAY USE THE BACK OF THIS FORM FOR DRAWING YOUR SITE PLAN. r SIDNEY F. HOOTS / I D.B. 175 Pg. 507 Nth / 11tip ✓gym // !i I N 33.47'22• E 'o, '? ------ / 231.61 = — / 'y0 0 qj -4. HOOTS \�� IJ0.006' 75 Pg. 504 LOT, ! / o 0. 0 16 7 ' /I I I \\ o `� �✓//'/ / \ \�\ �\\ ' �— ti°�- D L / / ! l / / r r I 1 N 14� g♦ \ l 4 •4 '9 • X12 � / / '�l I `\\` \` \ \ \i �t-�' �/ / �r l i i ' r i i i I I LOT #5//' h j i 1 / i i ' % i / ?36 OD I LOT #t6 _ rl —,� / \ r �` \ `�` �` —i/ j ! ' ' `^\ --_�� .r4j / !l Ql/ / ' / ' // /' 7 / I I i GS _ I , / W ' \\` ��` � � moi' ^ I � J ' /i�/' / � � ! I �/ / ' /' i / ' ' 1 � I • � LO /I[U �'' t cu n LOT PZa c� 4411/ �/ / \\ I I ! r``/` �, , � �/ / / / r 1 ;LOT1 I O ----- �.� ,' I / !6 c� i / / / i / ✓ iC / / \ '� — 150 -- -- 50 LOT #17 ttl -LOQ 1ffX,0 SICHr lj�'* > — — / LOT ' ' / I' ' ' / LOT\ #9 /(OT I I c // 3 �. �/ / ( ( I ► 1 I I I I ( / LOTH 1 n cv \ \142 �/ r 8 ,' I \ 1 11 ��I I �1 I j I I / q ca I N I , N 1 n1 �� II1J\ 1` � I It / / t6T #23% — r i i ' ,(�i \ ` 1 I 1 i / LOT1'� l 1 \ ' / 11 I I I \ 1 I I 1 i I / . 1 / 1 `4D' I / 1 N VOT,#2 /'•'LOT, 2�1 f!r, (r ( ; 130140 T$ ./ 504 ./ .--- ,' ,/ .��- /i' / .;%fes 'y /, y 1 671--� /' d / �� / NOTES � ALL LATS ARE SUBJECT TO DAME COUfM ///%/' J �� // / ' HEALTH DEPARTMENT STANDARDS. / l — 2. ROADS ARE TO BE BUIT,L • DAVIE COUNTY HEALTH DEPARTMENT ` Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME ® r DATE EVALUATED PROPOSED FACILITY PROPERTY SIZE SUBDIVISION �g2 KROAD NAME Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit rc./ Cut FACTORS 1 2 3 4 5 6 7 Landscape position 4- Slope% HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence i 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 SITE CLASSIFICATION: EVALUATION BY: �2/✓ 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 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) APPLIC TI R SITE EVALUATION/IMPROVEMENT PERMIFM ow IENLESSM Davie County Health Department /J Environmental Health Section U" P O.Box 848 Mocksville,NC 27028 (704)634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSE T / AIL/L THE REQUIRED INFORMATION IS PROVIDED. -� 1. Name to be Billed U D A ra /lfbd 5 Contact Person 6 N iA-►�1 -O Mailing Address 3:322 Home Phone 99k- R'g05 City/State/Zip 6/;EdV4/ 5,4Lmo /U.1?, 097106 Business Phone 91��" �� 7 2. Name on Permit/ATC if Different than Above J`rA ri+e- a Mailing Address City/State/Zip 3. Application For: Site Evaluation ❑ Improvement Permit&ATC ❑ Both 4. System to Serve: ❑ House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms # Bathrooms ❑ Dishwasher ❑ 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: ❑ 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? PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: 74, 10 Rc te-S 1 WRITE DIRECTIONS(from 1 Mocksville)TO PROPERTY: Tax Office PIN: # E7$9 - '76 - ST51 1 + 1 Property Address: Road Name 912P5 t o 1 1 OBJ �'erayta7�zG�- City/Zip d Awe e- A/e _ a70DG 1 �/ 1 If in Subdivision provide information,as follows: �� 0'Cl'! 1 f- yi8p ,!a'P Name: 1 4/v cl 0 rn 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 Aand owned by 'Tb iY . /100 5 to conduct all testing procedures as necessary to determine the site suitability. DATE g'- G"9 7 SIGNATURE Revised DCHD(06-96) P