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198 March Ferry Rd Lot 43 DAVIE COUNTY HEALTH DEPARTMENT J ' Environmental Health Section P.O.Boa 848/210 Hospital Street Mockwille,NC 27028 (336)751-8760 Account #: 989900025 Tax PIN/EH#: 5789-76-5851.43 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#43 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number: 3210 . 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 Fonn/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 WASTEWA C NSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �J Date: 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 LzfG.S.Chapter 130A, Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY e"4 quaran that the system will function satisfactorily for any given period of time. Y a Septic System Installed By: Environmental Health Specialist's Signature: Y/.li L/✓ Dater DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 989900025 Tax PIN/EH#: 5789-76-5851.43 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#43 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number: 3210 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 I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWA I E C NSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: 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. 7� )7111 ov Septic System Installed By:�� - (il Environmental Health Specialist's Signature: / y/��✓ Date: DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Sectionz— `' P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900025 Tax PIN/EH#: 5789-76-5851.43 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#43 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number: 3210 **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 1Z #Baths �Q — Dishwasher: Fr Garbage Disposal: ❑ Washing Machine). 2TO, Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste:❑ Lot Size Type Water Supply (10 Design Wastewater Flow(GPD) C2S� Site: NewEK Repair❑ System Specifications: Tank Size"GAL. Pump Tank GAL. Trench Width k:i�/ Rock Depth,/,? Linear Ft j�dj 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.**** Environmental Health Specialist's Signature: / Date: DCHD 05/99(Revised) f. APPUCATION FOR SITE EVAL iffinON/IMPROVEMENT PERMIT&ATC r Davie County Health Department D ' Envtitunmental Health Section P.O. Bos 868/210 Hospital Street DEC 71999 Mocksville, NC 27026 (336)751-8760 - e**XHPOE2TAHT*** THIS 71II1tLIC1►TICN t�tlaNO? 81f )PROCESSED UNL3S8 11I.L TIDE REQUIRED WTOMMILON 18 PROVIDED. Refer to the Iil'ORTrA X00 BULLETIN fox Lnstru/►ctions. ill 1. Maas to be Bed jjKJ//�{t 1216'/Zb add.CnAJ-%Z: Contact Person J//C1e/• AJ(V -e—&Q ) Kaillnq 7lddsess ,y� S U/II11 G-/�byF�IU LN , sows Pions q9a— 7577 cstp/stat•/s:p a70Afr Rn.inese racce, 99P- 7 79 1. Maas on Permit/7►'!C Lt Ditterent.than Above 1tailing address City/stag/sip 3. )Application For: )<81,te Evaluation 0 improvement Persiit/]►TC O Both s. systea to servioa: ,Rouse 0 Mobile Rome 0 Business 0 industry 0 Other s. if Residence: i people I Bedrooms ri1_0%_T 3 # Batbrooms Dishwasher I/aarb"M Disposal s j�Ww&1ns Uscbiae 0 Mas easnt/Olushing o Rasamant/Mo pluabLna bu S. it siness/Sadustrr/other: apeoily typet People i sinks i Commodes E showers i Vrinals f Rater Coolers I! IMSIMCE: I) Seats Estimated Mater Usage (gallons per wart 7. Type of water supply: County/City 0 Mell 0 Community a. Do you anticipate additions or expansions of the facility this system Is intended to serve? 0 Yea �No If yes,what type? ***IMPORTANT***CLIENTS MWCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMT17ED by the client with THIS APPUCATION. Property Dimensions: Ag—WJW- C a/_A.X4 WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: N `.rZ 7� -S S'I('W M 70 7-D f§O Yd Aif✓OAi Property Address: Road Name ( A6,01e 4-1 - GEFT r'h7 /'YIl ➢� City/Zip MA&i4 U)==3, U in a Subdivision provide information,as follows: /riQA G 9 Name: A R-C-1 Section: Block: Lot: Date Property Flagged: This Is to certify that the Information provided is correct to the beat of my knowledge. I understand that any permit(:) Issued hereafter are subject to suspension or revocation,if the site plans or intended ase change,or if the information submitted in this application Is Milled or changed I,also,understand that I am responsible for all 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 suitab DATE q SIGNATURE /✓ . 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): Client Notification Date: EHS: Account No. ops Revised DCHD(07/99) Involce No. tic/ -fi3o � w N r � N pro' l 42 ( 44J t431 N 4 � _ iz5' 0� 47 fool I� (Zp. �� Ion, ��)�•,, 126 rra eo J fv U �1 . n ,u' 1 /pal gam' I 0 X� � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account M 989900025 Tax PIN/EH M 5789-76-5851.43 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#43 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre Date Evaluated: .2111 ;0z) Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 2 3 4 5 6 7 Landscape position Slope% o (p2 HORIZON I DEPTH p- Texture group 41c_L, Sca- Consistence R-r'ssv Structure c!L Mineralogy (: 1 1: HORIZON II DEPTH -2 Texture group Consistence , S Structure $gL� MineralogyI 1: HORIZON III DEPTH Texture group } Consistence Pr C Structure g 1< Mineralogy - 1: HORIZON IV DEPTH Texture group Consistence Cr S 0 Structure P_ Mineralogyt t SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: P-S EVALUATION BY t7(iE LONG-TERM ACCEPTANCE RATE: C)-54> 0 OTHER(S)PRESENT: REMARKS: 1 Z- oy �Sap' r l9crey?- t tJ ceols-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 ois 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) LIAR-Long-term acceptance rate-gal/day/ft2 DCHD 05/99(Revised) Davie County Health Department o X1836 Environmental Health Section P.O. Box 848 . C� 210 Hospital Street Courier#.: 09-40-06 1911 Mocksville, NC 27028 Phone:(336)-753-.6780 ON-SITE WASTEWATER CERTIFICATION Fax:(336)-753-1680 (Check One) Replacement Remodeling Reconnection -Name: !rj� " /II L l�/�,P�S Phone Number �U1 (Home) Mailing Address: aSfiti' �(ili°,�il i - (Work) ��% Al Email Address: . N1 � I Detailed Directions To Site: o o- SI�!A r(4 F�'�' y �1 o u S Yz Property Address: E11Z h Fl(U Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: �//L'1� lU Type Of Facility: ((S /1 Date System Installed(Month/Date/Year): V Number Of Bedrooms: Number Of People: ti Is The Facility Currently Vacant? Yes No If Yes,For How Long? Any Known Problems? YesNo If Yes,Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: Number Of Bedrooms: Number of People Pool Size: orb X`'(� Garage Size: Other: equested By: %"/ XDate Requested: 3 O� LAI 012- (S ignatum For Environmental Health Office Use Only Approved Disapproved Comments: Environmental Health Specialist Date: /C2 *The signing of,this form by the Environmental Health Staf s in no way intended,nor should be taken as a guarantee (ex.Wndded or limited)that the on-site wastewater system will function properly for any given period of f'me. Payme Cam,' Check Money Order # Amount:$ Date: Paid By. 1 � 1 S Received By: ,( Account#: -5Z-7"1/� Invoice#: 105