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226 March Ferry Lot 40 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#: 5789-76-5851.40 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#40 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number: 2887 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. 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. r �J Septic System Installed By: ,,,,o 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 IMPROVEMENT/OPERATION PERMIT � Are-t �r, Account #: 989900025 Tax PIN/EH#: 5789-76-58551.40 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#40 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number: 2887 **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 ---? #Baths Dishwasher:jal", Garbage Disposal Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing: 0 Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste:0 Lot Size Type Water Supply_�G� Design Wastewater Flow(GPD) Site: NewX Repair System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width, Rock Depth Linear Ft--100 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.**** r Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) APPLICATION Davie County TIOHeaNth Department EMIT do ATC r a •` Envfionmenta/Health Section P.O. Bos 848/210 Hospital Street DEG 71999 Mocksville, NC 27028 (336)751-8760 ***IHPORTANTR** THIS APPLICATION CAM= 8W pROC. MM U=88 UZ THE RaQUIRZD I)WORM11TION IS PRCYIDED. Refer to the XNI' MWXCH BULIZTIH for instructions. 1. Manu to be Gilled Z?A,:I,, contact Person D/C1e-AAf4WW- 907th N.ilsng Address t t/r,*J c./yA 4L) LAI ') some mons q9A— 7 57 9 City/state/sZP J? 0c/CAV/t L.-!./1l. C. aR7o tx Business shone 9gE-_ 7.'.).7 s. Mama on Permit/1= if Diffevent.than Abate Nailing Address City/state/sip !. Application for: Site =valuation 0 Improvement permit/ATC 0 Both 4. system to services t(House O Mobile Some 0 Business 0 Industry 0 other s. If Residence: i people f Bedrooms rYl__T 3 i Bathrooms Dishwasher �("Zbava Disposal }Mashing Nuhins a sasesent/sliabing U sasement/Mo Pinmbing 6. If 11wfy iness/Zadustcy/Othesi Specit`y`pe i People • sinks Commodes t# showers i Urinals I water Coolers It IIMSERVICE: # Seats =atimated Water Usage (gallons per day) 7. Type of water supply: County/City 0 Well 0 Com®naity e. Do you anticipate additions or expansions of the facility this system is Intended to serve? 0 Yes �No If yes,what type? ***IMPORTANT***CWENTS MUST CDMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITZED§y the client with THIS APPLICATION. Property Dimensions: A,4V2d A /_A a.4 WRITE DIRECTIONS(from MoeWlle)to PROPERTY: Tax Office PIN: # SZ AN C/O Ta S 01 vn V&�,jaa4a Property Address: Road Name �i�E/C — GIFT (/�) /'Y11 Ft7 CityrLip IYIA Ce j W rrt 3 If in a Subdivision provide Information,as follows: lnA,0 G 9 Name: A 2c14 l•�OrSDS PA�tEe /�98 Section: Block: Lot: y� Date Property Flagged: This is to certify that the inlbrmadon provided is correct to the bat of my knowledge. I understand that any permit(s) 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. 1,also,understand that I ani respwulbleforall charges lncumd from tiles apppcatlom I,hereby,give consent to the Authorhad 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 soitsb . DATE I / " 9 �I 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 Dste(s): Client Notification Date: EAS: Account No. Revised DCHD(07/99) Invoice No. • 1A) J = qc � `T �O r. N. 5 -3D, 195 149 lam' 2Zc> r q'. c 0 ' " 12 I2� 12c 00 l C3 8 so, W 34- o I"►o� zoo' Or'L s` - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900025 Tax PIN/EH#: 5789-76-5851.40 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#40 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre Date Evaluated: --=� 11 O o Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L L Slope% 7 HORIZON I DEPTH b--7 Texture group Consistence $ Structure Mineralogy HORIZON II DEPTH Texture groupC Consistence G; P Structure Mineralogy1: HORIZON III DEPTH I -ZD 'Z:© Texture group C+2)!C Consistence Structure S k Mineralogy HORIZON IV DEPTH Texture group Consistence $ Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: \" EVALUATION BY: — LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: Jr REMARKS: 1�/�T�-- Ip �^3� 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) r