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234 March Ferry Rd Lot 39 r< DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section 6 ` P.O.Boz 848/210 Hospital Street 3 "� Mocksville,NC 27028 " (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900025 Tax PIN/EH#: 5789-76-5851.39 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#39 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number: 3350 **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 <—f' #Baths Dishwasher: Yu Garbage Disposal: Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow(GPD) J6,,� Site: New•e Repair❑ System Specifications: Tank Size/MP GAL. Pump Tank GAL. Trench Width ?!v Rock Depth/,�' Linear Ft.34�9 Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVE FFLUENT FILTER RISER(S) IF 6 11 BELOW FINISHED GRADE. ****NOTICE: Contact a representative a 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. on y of installation. Telephone#is(336)751-8760.**** j 1, 1 1 r � Environmental Health Specialist's Signature: // Date: DCHD 05/99(Revised) 3 DAVIE COUNTY HEALTH DEPARTMENT l Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 989900025 Tax PIN/EH#: 5789-76-5851.39 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#39 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number: 3350 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: X6 ,l/ 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. l 3� o� Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) APPUCATION FOR SITE EVAWATION/IMPROVEMENT PERMR&ATC r [R@ IE O W IE Davie County Health Department Envimmental Health Section P.O. Bos 848/210 Hospital Stmt DEG 71999 Mocksviller NC 27029 (336)751-6760 ***DwoRT7iy"" THIS APPLICATION C MT = M=SBBD UNLESS ALL THE REQUIRED INFORMATION IS PROVID ,�E/D. Rater to the the nVORK0101 BULLETIN for instructions. 1. stases to be Billed Acly le4Ald/�/2bGA/.Vi/VS� Contact lesson AC/e-4A1Ve.X-6aA) nailing PAdress pbons 4/9A- 7577 05 City state/s:p Aloc-&AylCIL4-6. Al C a 7oxs suainesa shone 7� 1. Mass on Ver ait/A= it Utterent.than above Y✓l Vailins Address Ci /state/SLY a. Application For: Site Evaluation Improvement Peraii.t/ATC 0 Both 6. Systea to servioss House 0 Mobile Rome 0 Business 0 Industry 0 Other s. If Residence: # People # Bedrooms f4osT'W 3 # Bathrooms 9 Ushrasber I/oarbMp Disposal �p J W&ddns Waohin• 0 sassasn�t/DloTabin� O a,assa.nt/Ho plumbing 6. 2t VusLn.ss/1n&=tx1/otb r, apsoity `hype # people # •mics # Counodes # above" # urinals # Mater Coolers It 1VODSERVICZ: i) Seats Estimated water Usage tQallona per say) 7. Type of Mater 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? ***IAfPORTANP**CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN RWTBESL/BW1M by the client with THIS APPLICATION. Property Dimensions: A,4WRt>A AI-A.:.4 WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax 081ce PIN: # S7 S-9 -? -S� j�39� AN (le) 7a Sao 1 vv ,P"A�-ea Property Address: Road Name &i2-E/C a - I-E c ' &J &V LZ Y-D Ci1y2ip /YlAto14 10&v J-Z I If in a Subdivision provide Information,as follows: /riA.D G 9 Name: A R-r'14 lyobDs .o��/�qg Section: Block: Lots 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 plans or intended use change,or if the information submitted in this application Is falsi0ed or changed I,also,understand that 1 any responsible for all cbaigcs Incurred front 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 sultab DATE L2 " 9 9 SIGNATURE 6- /✓ . � �-- 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. Revised DCHD(07/99) Invoice No. our, 3—7— v / A 3 I -3 c✓' � 19�� 14D l4D L 4i 12 O 00' 1381 a, � I !_►o` I top' 0gi I • DAVIE COUNTY HEALTH DEPARTMENT t • Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900025 Tax PIN/EH#: 5789-76-5851.39 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#39 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 Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L L Slope% (/ HORIZON I DEPTH SGL. O- Texture group O Consistence Structure ca C. Mineralogy 1' ; HORIZON II DEPTH g-2 -IX Texture group C Consistence Structure S 1L Mineralogy HORIZON III DEPTH 24 1 Texture group G+W Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATEn n SITE CLASSIFICATION: 1'S EVALUATION BY: F t�G•�`^'�' LONG-TERM ACCEPTANCE RATE: �'35 '� 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 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) LTAR-Long-term acceptance rate-gal/day/ft2 DCHD 05/99(Revised)