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235 March Ferry Rd Lot 36 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksviille,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900025 Tax PIN/EH#: 5789-76-5851.36 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#36 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre **NOTES* ffisb?mprov9ement/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: Garbage DisposaX10'*" Washing Machinee� 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) Site: New 0 Repair❑ System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width �Rock Depth Linear Fto2O 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) DAVIE COUNTY HEALTH DEPARTMENT d 10.1 T 01 Environmental Health Section '� P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 989900025 Tax PIN/EH#: 5789-76-5851.36 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#36 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number: 2952 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 CO TRUCTION IS VALID FOR A PERIOD FIV-)E YEARS. Environmental Health Specialist's Signature: Date: rC"-G C- _ 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. !d� ------------- r� Septic System Installed By: Environmental Health Specialist's Signature: oZl� Date: DCHD 05/99(Revised) A APPLICATION FOR SITE EVAWATION/IMPROVEMENT PERMIT&ATC Davie County Health Department Envimnmentyal Health Seactlon P.O. Box 868/210 Hospital Street ff(" 71999 Mocksville, NC 27026 (336)751-8760 ***I1wCRTAHT*** THIS APPLICATION CX=T = BROC szv UMSS ALL THS REQUIR= INl'OItMATION IS PROVID ''��E}}D. Refer to the INl'OMWZCH BULLETIN for instructions. 1. Bane to be filled /9/r//14A/dF_/2bdAl��1SF Contact person _ 1�I=AAr,62& dA.) WhilLog Address A A!5 W A)G• gAVEW LN � ao.. phone 4t9A- 7 5 7 9 citr/state/asf 1XDUtay/taae. ill. C. d 7o 9- f„einess Noone _ 9q9,- 7-'X7 f 3. Name on NocuLtATC i! Different than Above Whiling Address City/state/Zip P-�y"es4e-t g- +-c/ a. Application tor: Site =valuation 0 Improvestent Permit/ATC 0 Both s. eystea to aervicet House 0 Mobile Home 0 Business 0 Industry 0 Other s. If Residence: i People a Bedrooms M05kT-W 3 # Bathrooms l Dishwasher 7/aarbage s Disposal wasbing Dhohine 0 Basement/Wlluabing O faseasnt/No pluabiaq 6. it fust.ness/Zndnstry/other3 Zpsoify `type0 people # sinks # Cosnsodes f showers # Urinals i Rater Coolers if 1000SERVICS: # Seats latimated Water Usage (gallons per day) 7. Type of water supply: County/City 0 Well 0 Community e. Do you anticipate additions or expansions of the facility this system Is intended to serve? 0 Yes �No If yes,what type? ***IMPORTANT"**CLIENTS MU TCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MINT BESUBIRIM by the client with THIS APPLICATION. Property Dimensions: AAW A A/_AA Aex6�<S WRITE DIRECTIONS(from Mocknille)to PROPERTY: Tax Office PIN: # S'7 S-9 —-7 —S� ��3AN '70 7-0 S70 1 v-o Pe,0/xAFa Property Address: Road Name &Aegle -4 -GIFT �/�7 /YII Lz ?z7 City/Zip MA~ eC N W asM 3. If in a Subdivision provide Information,as follows: 1n4Aq G q Name: AAR-C" W OODs 96220yEL19900 Section: Blocks Lot: 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 use change,or if the information submitted in this application is falsified or changed I,also,understand that I ant responsiblejor all charges lncamd from this applicallom 1,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 sdtab DATE 9 9 SIGNATURE ��J- ZZ� THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include sH of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: EAS: Account No. O`2� Revised DCHD(07/99) Invoice No. (� 7 O PIN 3 3✓I B 401 v OD' �3Q�) o (3(t rL ' p' I7D� I zoo i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SoiVSite Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account M 989900025 Tax PIN/EH#: 5789-76-5851.36 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#36 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 Publicy Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 - 7 Landscape position Slope% /!7 HORIZON I DEPTH 6 Texture group Consistence Structure Mineralogy HORIZON II DEPTH 26;`�� Texture group Consistence r Structure /G 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 t / SITE CLASSIFICATION: 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 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)