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219 March Ferry Rd Lot 34 DAME COUNTY HEALTH DEPARTMENT -7 (j • Environmental Health Section P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT 989900025 5789-76-5851.34 Dick Anderson Construction Marchwoods Lot#34 Dick Anderson -- ---- Peoples Creek Road-27028 Residence 1 Acre 3121 **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 H #People #Bedroorns ? #Baths -?- Dishwasher: � Garbage Disposal: 13 Washing Machine.)21.1"** Basement w/Plumbing: 0 Basement/No,Plumbing: 0 Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 13 Lot Size Type Water Supply Design Wastewater Flow(GPD) Site: New,21' Repair 0 System Specifications: Tank Size 1P0 GAL. Pump Tank GAL. Trench Width, 41 J/ Rock Depth &L Linear Ft.,T& 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.**** S ��o� -e Id Environmental Health Specialist's Signature: �qate: —xf DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 989900025 5789-76-5851.34 Dick Anderson Construction Marchwoods Lot#34 Dick Anderson -27028 Peoples Creek Road 1 Residence Acre i a A 3121 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 WASTEWA ONSTRUCTION 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. qD Septic System Installed By: Environmental Health Specialist's Signature: Date: 2�z DCHD 05/99(Revised) APPLICATION FOR SITE EVAWATION/IMPROVEMENT PERMIT&ATC r .. , . Davie County Health Department D Enadronmenta/Health Swdon • P.O. Sox 868/210 Hospital Street DEC 71999 Mocksville, NC 27028 (336)751-8760 ***IMPORTANT*** THIS APPLICATION OUMOT BZ PM=MM MMZSS M THE REQUIRED 21WORMATION IS PROVIDED. Refer to the INFOMWICH BULLETIN for instructions. 1. :ams to be Milled dJ/Cl/4"4064&dA/•61##JS7- Contact p.r.m DIC/GAAfG�'+��5 Wiliuq Address o;A:5 til/.W a/M &A) L/✓ a acme phone q9A- 7 57 9 cit3r/state/sxp moc cAV/G .O". /I/. C• ;7o.x& stains. phone ggg-- 7-D-7 s. Naas on permit/ASC It Different than Above 1"Ung Address City/stab/sip s. Application For: Site Zvaluation 0 Improvement Permit/ATC 0 Both a. Systesl to Servioee ,House 0 Mobile Home 0 Business 0 industry 0 Other 5. If Residence: f People f Bedrooms M 3 e Bathrooms Dishwasher )�Oarbage Disposal ' s cashing Machine 0 sa.aa�ent//pluumbing o saeesent/Ho plusbiM 6. 29 ausiness/Zndustrr/other: specify `typeI people t Sinks / Commode. 1 Showers ! urinals • Water Coolers IF VOODSERVIC14: # Seats Estimated Water Usage (gain per der) 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 MUST COMPLEMTHE REQWRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESVBMiT ZED by the cUent with THIS APPLICATION. Property Dimensions: AAO2e0:C A/-A-D�ACOA J WRITE DIRECTIONS(from Mocb dlle)to PROPERTY: Tax Office PIN: # SZ g 7 6-615 1 r,3`) M C/O 7-V 2S O 19'O 0iP.,8R 13 Property Address: Road Name GIFT /-1 1Y11 Z6 Y CityPLip M,AtM l.UoM 3 If in a Subdivision provide Information,as follows: mQ,o G q Name: /yi R-0)4 W OLO.s 22A?gr�_./_ 98 Section: Block: Lot: J/ Date Property Flagged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) Issued hereafter are subject to suspension or revocation,if the site plans or intended at change,or if the information submitted in this oppUcation is falsified or changed 1,also,understand that I an responsible for aU charges Incurredfrom this appUcaliom 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 saltab DATE I� 1 " �I 9 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: ERS: Account No. d Revised DCHD(07/99) Invoice No. Qt 3-7-c 19� „ 14t" 14�� V R 40\ i I I:3, D0 3�) y 34 t\_ 1 / !�I ti.. I i r7o� Z py6 i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900025 Tax PIN/EH M 5789-76-5851.34 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#34 Reference Name: Dick Anderson Location/Address: Peoples Creek Road 27028 Proposed Facility: Residence Property Size: 1 Acre Date Evaluated: Water Supply: On-Site Well Community Public i� Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope% HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure S 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: �l 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 Mois 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)