187 Primrose Rd Lot 7 rtl,J -C-4 QQ-V1-+ -TJ(- u�4n ntl+;+or�url --- --- xGxs7 �, 1
a * APPLICA IION EOR SITE EYAUXTION/ISWROVEMElff PERMIT R ATC
Davie County Heelth Departrpgnt
'EnvinvnmerttalKealtfiSedron
P.O. Box ala/zle Hospitai stroet
Moccayi33s. NC 27934
(336)751-8760
•r•ndp0XTAIST•.. 27225 APPLXCXTZOU CAMIar BE RX0CSSSED OYU S ALL TAS RBQURRSD
XNY03MTZCN IS 7R0Y2t1SA. Refer to the XNT0 IA=0N B37U== for instructions. ,
✓1. srae. so be allied- / c4&ata&y 6USdA)
✓Stalling Jlfdresa �/N1t14A4t14!W LI11 Vtfu.e tramw y E1�'-757q
✓city/stete/za MAr4SVid— A4( R7039 --'suaiaesa phooi `f IS-7a.7q
(
,-2. %tear Oe t•etvle/ArC it 2L•t•rert than Above
11.11t.y mddresa Ctty/Statt/ziD
,—s. Application For, Ksito Iballlation 0 2aprovemo4t permit/JLTC 0 Both
-4. or.t.a t.8r.vle•t Uouse 0 mobile ]Ions• ❑ Business 0 Zndustry 0 other
.`i. 7yy eyat—rego"ted, 0 Cowentionsa ❑ coe,eetioeal uodlfted Q emovstive
.--s. If )t9aidenco, I Pocyle I Bedr000+s _ a Bathrooms
..r 7dDl.Lwela•r L7d.rbh•Dl.seral erkiaa ltee►!ae t]suu..t/tlu.btag ! ❑aue...s/Hr alr.Slwy
7. It%values./Ioduatty/ethars verify type t People f sinks
a Comaedes s hexer. s orinAle a Hater Coolers
Ir MI)SERVICEt 0�seaatts t.timst.d pat.; v.ag. tyauaot par e.yt
-mss. sypr of.rater supply, a'Cotm:y/City a well Cl Canmuaity
S. Do you aetleipete edditlone or expansions orthe facs'lity this system is intendod to serve?17 Yes 0Tq-
Ifyts,evhatl _
1MpoR7`it1Yl"•CLICI`rC.i dlt 7C0 IGETE THE REQUIRED PROPERTY INFORMATION REQUESTED
6 Euhera PLAT erSrrC PL rBESVBMrrrED b tbedtent with THIS APPLICATION,
tOYroperty Dimensions: S s 6!r�RtTE DIRECI'toNs ttrom Mocksvitic)to FROPERTY:
e✓i'ax office PN: a ?8 i
7 6 3�� 0 158 ro 0f S Tz) O�ot6-s
_,-Proptsty Addcea Read Name l� P�S GP +e��
city2p QVO v Cr- �7a zR
f in a Subdividou rovlde Inrorcuatl3n,asfollows:
Name: Mja/ecp&J21)4 c ygt4s6 4/J
Section: Block.-- IAh`_(� vffate home earn=Ragged:
TLis is to certify that the farorm76on provided is correct to the bat of my knowledge.I understand that lay permft(s)
issued hereafter are subject to suspension or revocation,If the site plans or intended use change,or if the iarormtion
submitted In this application is fafsikd or chanced.I,slip,im/ersrpnd shdr Jana rrrpons/btejer all eliprga Incurred from
Obis appUcediom I,Ittreby,give consent to the Authorized Representative of the Davie County Heal(h Dcpartment
to enter upon above described property locittd in Davie County and owned by
to conduct all testing procedures as necessary to determine the site su[t�bility.
DATE ..0 'G�.�i -O S --9GNATURE
THIS AREA MAYBE USED FOR DRAWING YOUR SIZE PLAN(Include all of the rotlo wing: Existirr and proposed
property lines and dimensions,stsuctur s.setbacks,and septic locations).
Site Rcvfdt CILat=C
Date($),
Client Notification Date:
EHS. '
2 � .5
Sign ev.. 6 Aeeount No.
Revised DCl'1D(10.5x03 Invoice No.
I
- DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLIC4NT TNFpRMATION PROPERTY INFORMATION
Tax PIN/.EH#: 5789-97-0344.07
Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Phase 4 Lot#07
Reference Name: Location/Address: Peoples Creek Rd.-27006
Proposed Facility: Residence Property Size: see map Date Evaluated:
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring I Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slo e% 22.E t
HORIZON I DEPTH -Z
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH ct
Texture group 5 ir-L
Consistence �5
Structure
Mineralogy ,
HORIZON III DEPTH 2A - .J
Texture group L
Consistence 1.15
Structure
Mineralogy
HORIZON IV DEPTH IdL
Texture group S-w
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION 5
LONG-TERM ACCEPTANCE RATE O-
SITE CLASSIFICATION: 101. U,,6 �i �1 �r EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS: qp-u 0 00CA t �s4
LEGEND
andscape 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
1exture
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-Prisrpatic
Mineraloev
1:I,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
.• 4 835 Tax Map:
• _ e Address:
Q 'S Installer:
jJ EHS:
Date:
hamber
Operati0 ermit Inspection Checklist
El Conventional C ❑ Polystyrene 0 Other
Location and Separation Distances
1. Distance from septic tank/pump tank to foundation/basement `J feet
2. Distance from system to well if applicable x feet
3. Any other setback(.1950)requirements
Supply line
1. Material supply line is constructed of 7\1 c- diameter inches
2. Length of supply line(2'min.) F-4(-
3. Amount of fall in supply line(1/8"per foot min)
4. Distance from ST/PT to the nitrification field/dist.device) feet
Septic Tank/Pump Tank ✓/
I. Visually inspect top of tanks(s),interior&exterior walls,baffle wall-and bottom
2. Any honeycombing or exposed rebar present? Circle: YES o NO
3. Visually inspect sanitary tee,lids,and air vent for proper installation and sealant
4. Tank Serial Numbers: STB r==XqPT
5. ST w/in 6"finished grade?Circle: YES or 1N0 t)Z W)
6. Date of manufacture: ST PT
7. Liquid capacity of tanks ST PT
8. Effluent filter type
9. Pipe penetration seal present?Circle: or NO
10. Riser(s)present?Circle: YES oltr o ser Type
11. Pump Tank riser 6"above finished grade?Circle: YES or NO ;1
12. Riser approved?Circle: YES or NO
,( Nitrification Field
1. Septic Tank outlet elevation
2. Trench Depth Readings(inches) ,
3. Number of Trench
Z Distance between trenches_r
4. Trench Width 3
Aggregate material type 1and size 3 4 5 6 57 (Circle)
�6. Aggregate Depth(inches)
l 2 7. Nitrification lines installed on contour?Circle: or NO
1
.? Innovative system type 1J/Pc Installer certified for installation?Circle: YES or NO -
�' 9. 2'earthen dam tween ST(or d box)and beginning of nitrification line?Circle:YES or NO
10. Stepdowns a be
a. undisturbed earthen dam(s) Circle: YES or NO
b. Proper rise over stepdowns?Circle: YES or NO
c. Solid pipe used? Solid,Corrugated or other?
d. Elevation of each stepdown
e. Are all stepdowns lower than the ST outlet elevations? Circle: YES or NO
Distribution Devices
1. Type / Is the device watertight? Is it level?
2. Distance from Dist.device to trenches feet
3. Record elevations:Inlets Outlets
4w. ,
OU
DAVIE COUNTY HEALTH DEPARTMENT l
y Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990002285 Tax PIN/EH#: 5789-97-0344.07
Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Phase 4 Lot#07
Reference Name: Location/Address: Peoples Creek Rd.-27006
Proposed Facilety- Residence Prnpp[ty qi7p- SPP MAP
ATC Number: 4344
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.
A4iEnvironmental Health Specialist's Signature: Date: ZZ7Z!��'-
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 1-30A,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: Date: A0,
DCHD 05/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
.40W. ," Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028 ` (�
(336)751-8760 v
IMPROVEMENT/OPERATION PERMIT
Account #: 990002285 Tax PIN/EH#: 5789-97-0344.07
Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Phase 4 Lot#07
Reference Name: Location/Address: Peoples Creek Rd.-27006
Proposed Facility: Residence Property Size: see map
**NO"IES*This improve3ment/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 3 #Baths
Dishwasher: ;!r Garbage Disposals Washing Machine:,0'e 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)t-?a Site: NewO Repair❑
System Specifications: Tank Size/,VZ) GAL. Pump Tank GAL. Trench Widths: / Rock Depth /2" Linear FtybO
Other: As stated in 1rA
sRequired Site Modifications/Conditions: accepted Systems may also be ueu
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISERS)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.****
Environmental Health Specialist's Signature: Aw Date:
DCHD 05/99(Revised)
v ctJ GJ VJ VL . 'T J('• ut4n r111ti.IC('AVtI JJ0 +7+70 1 G f �• 1
APPLICA[MY FOR SITE EYAU1ATION/t31PROYE11EW PERMIT&ATC A I /k.,
• Davie C3D
ounty Health Department (�Gt/u '_` 1 l
'Env11anment21KdJ11hSedi0a
P.O. Box ane/zlo Hospital st:raat
Mocica71114, PC 27930
(336)751-8760
v..XXP0A7AWT... TBIS APFLICtTION CAMWr EM PROCSSSED MMMIS ALL TAS M MQIRM
ImPORHITIOA Is YRUVU=- Rofer to the Ir7r'OIZDA=ON EDLLETIli for ioetructioan.
✓i. tress to as 3111.4I XZ2&a9 -&d 6,C)S T1A/G(fie nc.cc s•r.on 7/C/L�iV '-Bd A)
✓jt.tiing Afdr•sa 5 f l)/AlG.,14Ar zw 4111 (/lfowe Plavee S/9�-75y9
✓city/st.te/zir /YIAC;j,--.s/Id�. x7038 t a.ibos,noon 7.2,7q
a�a. Ker•.P•tatt/ATC if O ••rer.0 tAan Above
►tell tag address ctcy/st.to/zip
ri. Application tors Ksits Iltaluation l7 Zaprovo=41: pazmit/ITC ❑ Both
,-4. or.%"to Boa+/.•, C(IIaume M mobile Baine ❑ sasinoaa ❑ Iaduatry 17 Other
.rL. 'typo eystw rogvosted. ❑ coa-ontional d con+•&noxa%iodift•d 0 iaso•stiv
mss. IIf Neesidences t popple P Bedroono _ a Bathrooms
1 aQOi,lw.ta.r IZO.rby DLpe..l ..lip M.aw. ❑tuewtJslublsg ❑suer.tAM F1,sSlwg
1. It ousters/iDdustry/other: vorify type a People a Stake
I Cm.od.e a£aeo•ra a Orieale •Wear c"Iers
IT TMI)SERVIt.3t A Seatt )(lomat-d Maur 17pa9v (y£uDn.Per day)
--mss. Typo of-ter supply, �Co Uty/City ❑ wall ❑ Com maity
J. Do you anticipate.dditloda or txpans(otts of the faaltty this system is intetrdtd to scree?O Yes ❑'1`fo
Ilycs.whaft ' ___
meoRTANI"'cuie'Il`.i MUSTCo PLLTE THE REQUIRED PROPERTY INFORMATION REQUESTED
e Ud,cra PLAT or SRC PL %'VST BESUBMI1TED by the client srhh THIS APPLICATION.
t--'f►operty Dimensions: �J, _S 2M 6k g- RITE D)RBCTIONS(from Mocksrttte)to PROPERTY:
,
*—Tax office M. a 78 '7 158 110 X01 S 7D P2�0ye,E-S
_-Proper(yAa mm PAad Name l�CIJPG�S
«tyrzip
f in a SubdlYidaa rovlde IaforetaH]A,ss tallows:
Name. /y] lecfy(9/ana c
Section: Block: Lot: -9-11 &-late home corners(lagged:This it to certify that Ike information provided lc correct to the best army knowledge.I understand that any perMit(s)
issued hereafter are subject to suspension or revocation,If the site pians or intended use change,or if the information
submitted In this application isfAsifiedorehm¢tsL 1.slss,r dersrnandlherJR,srespons)blejorafieTierra7Acnrredjrom
this appmearlon. 1,hereby,give consent to the Authorixed Representative of the Davie County Health Department
to eater upon above described property located in Davie County and owned by
to conduct all testing proccdures as aecraaary to determine the site sul ,
L--DATE el -cZ.Oi-o S a-StcNATORE - -�
TATS AREA MAYBE USED FOR DR,tWIN•C YOUR SIZE PLAN(Include all of the following: relisting and proposed
property line and dimensions,struclums,setbacks, and septic locations).
Site Rc►fdt Charge
Date(s):
Client Notification Date:
ERS:
Sign given� Account No.
Rerun-DOD(05103 Invoice No.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #7WT002285 Tax PIN/EH#: 5789-97-0344.08
Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Phase 4 Lot#08
Reference Name: Location/Address: Peoples Creek Rd.-27006
Proposed Facility: Residence - Property Size: see map Date Evaluated:
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Sloe%
HORIZON I DEPTH
Texture group5 ti
Consistence F- rap
Structure
Mineralogy
HORIZON II DEPTH 7
Texture groupC
Consistence ,
Structure
Mineralogy
HORIZON III DEPTH
Texture groupW,("C>
ConsistenceStructureMineralogyHORIZON IV DEPTH sFj -4
Texture groupConsistence
t-
Consistence ►-
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATELar
SITE CLASSIFICATION: 0S QS & k;> C_-)IEVALUATION 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 VFl-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-Prisrpatic
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
DCl ID 05/99 -Revised-