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189 March Ferry Rd Lot 31 DAVIE COUNTY HEALTH DEPARTMENTmoo— Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900025 Tax PIN/EH M 5789-76-5851.31 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#31 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number: 2654 **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 // #People #Bedrooms I�Y #Baths Dishwasher: Zf" Garbage Disposal: 12f Washing Machine:Ey"' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size d L"LAC Type Water Supply Design Wastewater Flow(GPD) Site: New GK' Repair❑ System Specifications: Tank Size�l7GAL. Pump Tank GAL. Trench Width kTr Rock Depth c)2-�L�Linear Ftz��✓ 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.**** l YJ 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#: 5789-76-5851.31 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#31 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number: 2654 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 WASTE 7n= A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: 2, � 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. ve Frr Septic System Installed By: Environmental Health Specialist's Signature: Date: f �� DCHD 05/99(Revised) APPLICATION FOR SITE EVAUJAT10N/IMPROVEMENT PERMIT&ATC Davie County Health Department D • Envfronmentol Health Section ' P.O. Bos 848/210 Hospital Street (1�:.(� 71999 Mockaville, NC 27028 (336)751-8760 ***I1+lpORTANTe** THIS "RWCATION Cumm = PROmsm UNLBSS ]ILL TH>C UQUIRED INICOF*WX0N IS PROVID�/EJD. Refer to the INI'ORMATICH BULLHTIH for instructions. 1. Name to be Billed Z?x/r ftn/,t�r��2bea/,l r�S Contact Person A-C/C.)9AfGeA-'AdA) Mailing Address ann,,A s (Al.'A)G-14bV eW L om Al i ce shone C19A- 7 s 7 /i'[ City/state/sIP OC&AV-1(, ,.- Al.NC a 70A& &,sines. phone 9¢&- 7A7 2. Naas on Permit/A= if Different.than Above Mailing Address city/state/sip a. A"11cation For: Site =valuation 0 Improvement Permit/ATC 0 Both e. system to service: House 0 Mobile Rome 0 Business 0 Industry ❑ other a. if Residence: # People # Bedrooms rAQSrul 3 # Bathrooms Dishwasher 3�Oarbags Disposal j�Nasbing Machine O &aseawnt/P1u ft&V 0 &asement/m, PUnibing 6. If &usiness/Industry/Other: specify `hype # people # sinks # commodes # showers # Urinals # Yater Coolers IF rCODS&MCZ: I) Seats Estimated Yater Usage (gallonn per day) 7. Type of water supply: Kcaunty/City 0 Well 0 Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes �No Uyes,what type? ***IMPORTANT/**CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUSTBESURNITTED by the client with THIS APPLICATION. Property Dimensions: A021W 1C a/-AA Act, WRITE D'ILREC IONS(from Mocksville)to PROPERTY: Tax 08ice PIN: # S — 4/s/) AN C/O Tb SSD 1 v-o Piar3F B Property Address: Road Name ('Vgegle 4-1 - I-EFT (/-j mi Le rD City/Zip IY)p1?Cij tOaszM3 If in a Subdivision provide Information,as follows: In4o G 9 Name: MAr2014 W obDs '004nuu 1-egg Section: Block: Lots Date Property Flagged: This Is to certify that the information provided Is correct to the best of my knowledge. I understand that any permit(:) 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 arts responsible for aU charges Incurred frons 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 snitsb . DATE //7- -) " 9 9 SIGNATURE JZ-6�� THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property line and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(&): lit E Client Notification Date: ERS: Account No. i Revised DCHD(07/99) Invoice No. / 124 � o N N fy G ��6 1 lay ( 44 Iz5 ' 0� N 4--7 �] 1io, L I z() �j 126 17o, IN. ,p 1it'll I10� iZD' Rc x I tA __ 054 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900025 Tax PIN/EH#: 5789-76-5851.31 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#31 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre Date Evaluated: D Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit r/ Cut FACTORS 1 2 3 4 5 6 7 Landscape position ,Z Slo % ,c HORIZON I DEPTH G Texture group Consistence Structure Mineralogy HORIZON II DEPTH -96r' Texture group (i 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: a �Z 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)