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122 Oak Hill Rd Lot 72 ` DAVIE COUNTY HEALTH DEPARTMENT /f� Environmental Health Section -� P.O.Boz 848/210 Hospital Street Y • t Mocksville,NC 27028 .t (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900025 Tax PIN/EH#: 5789-79-5851.72 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#72 Reference Name: Location/Address: Old March Road-27006 Proposed Facility: Residence Property Size: see map ATC Number: 3374 **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. i Residential Specification: Building Type #People #Bedrooms #Baths Q,.5 Dishwasher Garbage Disposal: ❑ Washing Machine:• Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Wastewater Flow(GPD) Site: New Repair❑ System Specifications: Tank SizeGAL. Pump Tank GAL. Trench Width,��Rock Depth ,Linear Ft-700 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.****W.41er dv 'A F Environmental Health Specialist's Signature: / Date: C2 �l1cJ "vim DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT t , Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 989900025 Tax PIN/EH#: 5789-79-5851.72 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#72 Reference Name: Location/Address: Old March Road-27006 Proposed Facility: Residence Property Size: see map ATC Number: 3374 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 OOF/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. / 63xay Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) j �•,. APPLICATION FOR SITE EVALUATION/1MPIIUVFh9ENT PL-ItS11T& �t Davie County Health Department L� EnvironmenW health Section P.O. Box 848/210 Hospital Street �fAY Mocksville, NC 27028 (336)751-8760 INV11 EN,#Q ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS AL1,_TH 1� W UILTH INFORMATION IS PRROVIDED. Refer to the INFORMATION BULLETIN for instructions-. _�� 1. llama to be Billed ,%jC/C�� d.L) t UR 1S% �� Contact Person Mailing Address r� &/I,t/,5- AZA,,t=.4J L,,LI Home Phone �f%��- -7 .2 ---- City/State/ZIP 146JGs1//cam r_ ,L/,(!. 70,2d' Business Phone -)-A 7 2. llama on Permit/ATC if Different than Above Mailing Address City/State/Zip � on 3. Application For: X Site Evaluation ❑ Improvement Permit/ATC II Both 4. System to Service: House ❑ Mobile Home ❑ Business 0 Industry IJ Other 5. If Residence: @ People # Bedrooms _ it-Bathrooms D II Dishwasher ll Garbage Disposal t.) Hashing Machine L1 Basement/Plumbing II Basement/Pio Plumbing 6. If Business/Industry/Othor: Specify type A People It Sinks 11 Commodes 0 Showers 6 Urinals 1) Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) �- 7. Type of water supply: County/City U Well II Community Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes H No If yes,what type? ***IMPORT/INT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQIJ ;S'I,I? DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATIONPROPERTY INFORMATION ccoun Tax PIN/EH#: 5789- - Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#72 Reference Name: Location/Address: Old March Road-27006 _ Proposed Facility: Residence Property Size: see map Date Evaluated: Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit I Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope% HORIZON I DEPTH -Y 4' Texture groupC Consistence Structure Mineralogy HORIZON II DEPTH �� •G {i Texture group Consistence r 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: / 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 MineraloQv 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 05/99(Revised) Health Department a �� 61 vlro ntal Health Section .� Y. - ,�� O. Box 848 a M !' 2 AY 21 Hospitzl Street � mt s a Cou ier# : 09-40-06 0MRONMEwhL"H " Mock ville, NC 27028 ppVIE COU0 Plione:(336) -753-6780 Fm:(336)-753-1680 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnections Name: 4 r1jrlUAI Al Phone Number J �1 C9 y U" � (Home) Mailing Address: p� (Work) ALL �. Detailed Directions To ite: el'Al !� -Aa-,�Ll� v 4`12 Property Address: l Please Fill In The Followin Infor tion A out The EXISTING Facility: Name System Installed Under: Type Of Facility: Date System Installed(Month/Date/Year): I � Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? Yes N If Yes,For How Long? Any Known Problems? Yes ( Ng/ If Yes,Explain: �/ i Please Fill In Th�IFollo i g Info matin bo t�Th V. N(E�WpFahcil. Type OfFaciliV( i Q" `"� �S Q/ NObmber.OPBedrooms: '� N er of People S�6Requested By: Date Requested: �� ure) For Environmental Health Office Use Only Approved Disapproved Cn t ( , f!� Comments: .1@r � C o� e s Environmental Health Specialist Date: 522(o�jlj�0 *The signing of this form by the Environmental Health St ff is in no way intended, nor should be taken as a guarantee (extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment Cash Check Money Order # Amount:$ Date: Paid By: ,,, �y t Soh ,,,..-.,d. am . ved By: Account#: 7 P In #: e7. .3 u A S Z7-4J Glr��L, 1a y. .. .. AIR) ._. __ . . 4.8 -LJJLA u•a