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190 March Ferry Rd Lot 44 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section - P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900025 Tax PIN/EH#: 5789-76-5851.44 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#44 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre **NO I�**'TliisNproveement/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. 1 Residential Specification: Building Type #People #Bedrooms f #Baths Dishwasher: Garbage Disposal:e Washing Machine:e Basement w/Plumbing:❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type /1 #People #People/Shift #Seats Industrial Waste: ❑ Lot Size l r.4G Type Water Supply C Z) Design Wastewater Flow(GPD) Site: New❑ Repair❑ ?/ Ie ,1 ' System Specifications: Tank Sizef GAL. Pump Tank GAL. Trench Width L Rock Depth� Linear F 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.totallation. Telephone#is(336)751-8760.**** • U 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 M 989900025 Tax PIN/EH M 5789-76-5851.44 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#44 Reference Name: Dick Anderson Location/Address: Peoples Creek Road 27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number. 2567 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 PERIOD OF FIVE /YEARS. Environmental Health Specialist's Signature: ✓ ' Date: L 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 1 I 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. ,S l L o 7it L zo Septic System Installed By: 2 Environmental Health Specialist's Signature: Date: f l—dD DCHD 05/99(Revised) &C-/d w APPLICATION FOR SITE EVAWATiON/IMPROVEMENT PERMIT&ATC @ a Davie County Health Department D • Envlronmenta/Heat/th Sect lon P.O. Box 868/210 Hospital street OEC 71999 Mockaville, NC 27026 - (336)751-8760 ***DWCRTANT►** THIS APPLICATION CUNOT BN PROMMM UN1388 ALL TIM R3QUIR3D INFORMATION I8 PROVIDED. Refer to the XWORMIITION BULLETIN for instructions. 1. xaus to be Stu" Aux,4"nase bea/*6 ,V S4- contact person >�1UG�iel G►t`�SdJt� lfaslsnq address @ A S CA1IA1 a 14AVEA/ LA/ .) soee ftone !df A— 75-7,0 Csty/state/s=p I;f0CJCAVl t't.&. J. C. a 7o t& susiaea. aboae (Y - 7A71^ Z. xaa on pewit/AIC i! Di!larant.tbaa Above i:aiunq Addreas Citr/state/a s. Application For: )<Site =valuation /Improvement Permit/ATC 0 Both e. srst n to servioel t(Bouse 0 Mobile Home O Business 0 Industry 0 Other S. If Residence: # People ; Bedrooms OMPST-i-V 3 f Bathrooms Dishwasher )(oarbaga Disposal ` j MoUnq l WM=e 0 Muenan�t/Plumbinq o sasdeut/xo plumbing G. ZE Dosinase/=n&Mtrr/otMr: ap.oirr `typa # people t sinks ! Cannodes / showers I vriaals i Nater coolers I! FOODBIRVICS: # Seats Estimated Nater Usage (gallons per day) 7. TAM Of Vater supply: County/City 0 Well 0 Community a. Do you anticipate additions or expansions of the facility this system Is Intended to serve? 0 Yes �No If yes,what type? ***IMPORTANT'***CWENTS MWCDMPLE7ETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MLW BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: AMMO K A I_P,A A WRITE D'lRECTIONS(from ModuMlle)to PROPERTY: Tax Office PIN: N v`7 ! 7 "s� ��y > 70 TV fSQ a,Fa Property Address: Road Name &A 40,c, 6D - L.,r=FT C/al /YII 4E To City/Zip /YlptC4 W zM 3 If In a Subdivision provide Information,as follows: /riA,4 G q Name: A-AR-04 wo&Q-% Pmt /q.gg Section: Block: Lot: Date Property Flagged: This Is to certify that the information provided Is correct to the but of my knowledge. I understand that any permit(s) Issued hereafter are subject to suspension or revocation,if the site pians or Intended we change,or if the information submitted in this application is falsified or changed. I,also,understand that I ani respoulble for all charges lncumd from ibis applicadom I,hereby,gale consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located do Davie County and owned by to conduct all testing procedures as necessary to determine the site snitch �►Q DATE /A -) " 9 9 SIGNATUREJ/✓ .e THIS AREA MAY BE USED FOR DRAWING YOUR STTE PLAN(Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: EIIS: Account No. 0 n � Revised DCHD(07/99) u� �' Invoice No. �y � r 1 � tyo � 140' f 4z 43 44 IZ5' pg 0. 4.7 rfo' �- 12p' fZF f/p' eo l u / \l o O' r 'to .00pgl I n X f N 4 �\� DAVIE COUNTY HEALTH DEPARTMENT ~ Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900025 Tax PIN/EH M 5789-76-5851.44 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#44 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre Date Evaluated: Z—F-1 00 Water Supply: On-Site Well Community Public ✓ Evaluation By: Auger Boring Pit _11� Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope% ?� HORIZON I DEPTH O-- t>-10 Texture group ZIC-L- Consistence Structure Cf— Mineralogy1 ): HORIZON II DEPTH 10-7,2- Texture 0-22Texture groupC, Consistence Structure k Mineralogy 1: 1 HORIZON III DEPTH 1 -,72--3,4 Texture group Consistence s Structure MineralogyI; HORIZON IV DEPTH 2 Texture group Consistence Pr Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE( 0. PSI p. SITE CLASSIFICATION: S EVALUATION BY: � a' tX.4_1AX LONG-TERM ACCEPTANCE RATE: ©' �• OTHER(S)PRESENT: 1, I�14J REMARKS: S•W W. IQ ST _CAKS c SD.Q c�1 1 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)