157 March Ferry Rd Lot 28 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
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Account #: 989900025 Tax PIN/EH#: 5789-76-5851.28
Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot 28
Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028
Proposed Facility: Residence Property Size: 1 Acre
ATC Number: 2978
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 I 1 of
G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEW R CONSTRUCTION IS VALID OR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: �. t;4, Date:
� �Bc�rzoo�S
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 I 1 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 B
eP Ys :Y
Environmental Health Specialist's Signature: Date:
DCHD 05/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
' - Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMI�AS7 19-4129h
Account M 989900025 Tax PIN/EH M 5789-76-5851.28
Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot
Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028
Proposed Facility: Residence Property Size: 1 Acre
ATC Number: 2978
**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 I I 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 Ir,-? #Baths
Dishwasher:: Garbage Disposal: Washing Machine;, Basement w/Plumbing:71 Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seatts Industrial Waste: ❑
Lot Size Type Water Supply Design Wastewater Flow(GPD) (761J Site: NewEr Repair❑
System Specifications: Tank Size� it I
��GAL. Pump Tank GAL. Trench Width c��• Rock Depth Linear FtgW
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.o day of installation. Telephone#is(336)751-8760.****
't
Environmental Health Specialist's Signature: Date: /d" !�1Y,- ✓
Loll
DCHD 05/99(Revised)
APPUCATION FOR SITE EVAWATiON/IMPROVEMENT PERMIT&ATC
• , ' • • Davie County Health Department D
Environmental Health SeWon
P.O. Box 868/210 Hospital Street Dl E, 71:99
Mocksville, NC 27028
(336)751-8760
***IMPORTANT*** THIS APPLICATION =MW BN PROMSRD UNLESS ]ILL THE REQUIRED
IN>i'ORMi1TION IS PROVIDED. Refer to the ZNIt'ORMATICN BULLETIN for instructions.
1. Maas to be sillsd Ae//4"ae a eA/•6n#J S F- contact Arson _D IVB-/'ticl 4)
Nailing Address A A:5 W tA)G•14A 4L) l-Al some phone WA- 7 5 7 7
City state/z2p MOCIC Zvi c,c..c 0 Al.. C. a 70A 9- scariness Whose 9q8. 7A7�
i. Maas on perait/MM It Oiffwmat.than Above
Nailing Address Cit=/stats/zip
!. Application for: )<Sits Evaluation 0 Improvement permit/ATC 11 Both
e. system to services House 0 Mobile Home 0 Business 0 Industry 0 Other
s. If Residence: # people # Bedrooms �'Y!_t2Sr��a1 3 # Bathrooms
Dishwasbsr �("Zbaoe Disposal }pJ w"hing Naobine 0 au�saant/pllJ2-%42% 0 bas isent/No plumbing
S. it nusiness/2nduatsy/others specify `type` # people # sinks
# Commodes # showers # Urinals # hater coolers
I! FOODSERVICE: # Seats Estimated Dater Usage taanons per day)
7. Type of water supply: County/City 0 Well 0 Community
s. Do you anticipate additions or expansions of the facility this system Is Intended to serve? 0 Yes �No
If yes,what type?
***IMPORTANT***CLIENTS MISTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPUCATION.
Property Dimensions: AR"X0 K AWRITE DIRECTIONS(from MockMlle)to PROPERTY:
Tax Office PIN: # S72-2 Ito ".S��11,2�) M 70 7-0 � O 17-0 Vej6a&A _
Property Address: Road Name ("ieeE/C a - I-E Z:r C/-I /YIl L�s 7-D
City/Zip MAt l) LU try 3
U in a Subdivision provide Information,as follows:
M410G q
Name: MAR-04 W 060z'
Section: Block: Let: �� Date Property Flagged:
This is to certify that the information provided is correct to the but of my knowledge. I understand that any permits)
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. 1,also,understand that I aril msponsible 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 and owned by
to conduct all testing procedures as necessary to determine the site snitab �rQ f
DATE /-2-1 " 9 9 SIGNATURE /.J .C..�
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Date(s):
y' �/o Client Notilication Date:
T C_ `a-`l-? EAS:
2f�onecus�y �' +
Account No.
�' r
Revised DCHD(07/99) r Invoice No.�✓
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t
DAVIE COUNTY HEALTH DEPARTMENT
. Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 989900025 Tax PIN/EH#: 5789-76-5851.28
Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#28
Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028
Proposed Facility: Residence Property Size: 1 Acre Date Evaluated: .2 //—b0
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit 11 Cut
FACTORS 1 2 3 4 5 6 7
Landscape position �.
Slope%
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH C
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 c
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
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)
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