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132 Oak Hill Rd Lot 70w 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 Billed To: Dick Anderson Construction Reference Name: Proposed Facility: Residence Tax PIN/EH #: 5789-79-5851.70 Subdivision Info: Marchwoods Lot # 70 Location/Address: Old March Road -27006 Property Size: see map ATC Number: 3423 **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 A/ #People #Bedrooms #Baths . J Dishwasher: Zr Garbage Disposal: ❑ Washing Machine: Ja Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply_ Design Wastewater Flow (GPD) Q&a Site: New Repair ❑ System Specifications: Tank Sizer/ MR_ GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width Rock Depth _?_ Linear Ft.3,ODl IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 L° 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.**** Environmental Health Specialist's Signature: Date: ! `91- 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 #: 5789-79-5851.70 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot # 70 Reference Name: Location/Address: Old March Road -27006 t -acuity: Residence ATC Number: 3423 Nroperty 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 WASTEWATER CON TRUCTION IS VALID FOR A PERIOD jOOF FIVE YEARS. Environmental Health Specialist's Signature: Date: ` `9 wb-f 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) — 2a •, ... , /,fid .•,, •,. APPLICATION FOR SITE El/ALUATION/IMPIIOV[h9FNT PCRRIIT Davie County Health Department Envi=imenia/Health Section V P.O. Box 848/210 Hospital Street "y Mocksville, NC 27028 5 2002 (336) 751-8760 ENVIV * * * IrSPORTANT* * * THIS APPLICATION CANNOT BE PROCESSED UNLESS lk—a-'TH' �Qi(l�a INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions -- 1. llama to be Billed 412th(, 33),-0, 60x-5 ��ur_ Contact Person Mailing Address � • .� C(/I Al -- /7`AZi - XJ L,,GI Home Phone 'f %.•� - %� 7 --- -- City/State/ZIP > a1�✓/C r _ �/, C. Business Phone -)-A 7 2. Name on Permit/ATC if Different than Above Mailing Address City/State/'Lip — 3. Application For: XI Site Evaluation ❑ Improvement Permit/ATC II Both 4. system to service: )(House ❑ Mobile Home ❑ Business 1.1 Industry IJ Other S. If Residence: 11 People Bedrooms_ t1 Bathrooms 1.1 Dishwasher LI Garbage Disposal L.1 Washing Machine L1 Basement -/Plumbing II BasemenL/No Plumbing 6. If Business/Industry/Othor: Specify type 1I Co=odes 6 Showers N People 11 Sinks 0 Urinals 11 Water Coolers IF FOODSERVICE: #t Seats Estimated Water Usage (gallons per day) _ 7. Type of water supply: County/City ❑ Well II Community Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes I] No Ifycs, what type? l ***h{lPORTANT*** CLIENTS MUSTCObiPLLTETHE REQUIRED PROPERTY INFORMATION REQl1 ,Sfl?U I \ L ( BELOW. Eitlwr a PLAT or SITE PLAN 6IUSTBESUBAfl7TED by the client vvitli THIS APPLICATION. Gl�i4 V/CL 1 Property Dimensions:�% T>'e, WRITE DIRECTIONS (from ( Iochsville) to I'I(UI'PATY: 77 SI Tax Office PIN: # Property Address: Road Name OG/j 41i92ca/ 49/')'lo�csdl�cc �� dfloyCc ,.f/,v fia City/Zip /70VAUC'= , 27604 L6A,— .bio (/) ,ojic�c If in a Subdivision provide information, as follows: 7Z) 1514,ec/y Uloo/o ,5 o.y 2r - Name: MA1,241-4 UbGPS .5 Section: IF 4 Block: /" Lot: ' O Date Pronerty Flamecd: i!lirc'/l O This is to certify that the information provided is correct to the best of my knowledge. I understand that any Ilcrmil(s) issued hereafter arc 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, untlerstand that I ant responsible for all charges incurred fruill !Iris opplicalion. I, hereby, give consent to the Authorized Representative of the Davie County IIcaIIli DepaHincnI to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site nk� DATE J — O �. SIGNATURE Al THIS AREA MAYBE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic Iocations). Revised DCHD (07/99) fl� 4' h �Z t� Site Revisit Charge Date(s): Client NotiFication Datc: EHS: Account No. 1L 1 7 ooa 2z' 5 Invoice No. e'O DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account M 989900025 Billed To: Dick Anderson Construction Reference Name: Proposed Facility: Residence Property Size: Water Supply: On -Site Well PROPERTY INFORMATION Tax PIN/EH M 5789-79-5851.70 Subdivision Info: Marchwoods Lot # 70 Location/Address: Old March Road -27006 see map Date Evaluated: 07 Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH �� ✓ Texture groupG Consistence Structure Mineralogy HORIZON II DEPTH 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 RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION 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 DCHD 05/99 (Revised)