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237 March Ferry Rd Lot 37 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 989900025 Tax PIN/EH M 5789-76-5851.37 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#37 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre 11**NOT> * iis�finpro a me nt/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 /7 #People #Bedrooms SSI' #Baths v�•5 Dishwasher: e Garbage Disposal:Er 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) Site: New❑ Repair❑ System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width JJ� Rock Depth,22.� Linear Ft.�g Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6 K 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: '16 P !� DCHD 05/99(Revised) " DAME COUNTY HEALTH DEPARTMENT 1 Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 989900025 Tax PIN/EH M 5789-76-5851.37 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#37 Reference Name: Dick Anderson Location/Address: Peoples Creek Road 27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number. 2620 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 CO STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: ,Zn 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 I 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. F qL 7L G. Septic System Installed B : eP Ys Y Environmental Health Specialist's Signature: �p{/LQ Date: DCHD 05/99(Revised) j APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC r a Davie County Health Department n Environmental Health Sectlon +� P.O. Box 868/210 Hospital Street j DCI 71999 Mockaville, NC 27028 (336)751-8760 - ***nWCRnNT*** THIS APPLICATION CAVMT BN pROMMM UNL288 ALL THE REQUIRM INFORMATION IS BROVMZD. Refer to the IWORMTION BULLBTIN for instruations. 1. Mame to be Billed Z?-/C//14"46A66a/,6^01.s7" Contact person D1C/CG)'?Ara&Wb0A) Hailing Addreasy/��,,�S lI�/�I�G•/�l�4yIU L N , Rome Phons q9A— 7 57.9 City/state/dip l�'[OCICA V/t.t.re, Al.VC a 70A X- Business Phone s. Mame on pewit/M It Different.than Above Hailing Address City/stag/sip 3. Application For: Site =valuation "'O:A provement permit/ATC 0 Both e. Systam to service: t(House 0 Mobile Homo O Business 13 Industry 0 Other s. If Residence: s people ; Bedrooms m�r�l1 3 f Bathrooms Dishwasher /"Zba" Disposal )(Washing Htaobine O Baeement/plumbing 0 Basament/Mo plumbing 6. If Business/Zuduetsy/Others specify two • pooplo 0 sinks if Commodes # showers I (:viols i Water Coolers I! FOODSZRVICE: # Seats Estimated Nater Usage (gallons per day) z. Type of Water supply: County/City 0 Nell 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 MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: A,4VX0 K A/-a A 4 WRITE DIRECTIONS(from Mocksvllle)to PROPERTY: Tax Office PIN: # 5-7 9-2 —7 6 —Lg;I4,V) 0_ t10 7-0 270170 puri!' Property Address: Road Name ( 'I cele a — LEFT"_ (/�) /YI)LA Y-D City/Zip /YlAtM tV=.=, 3 If In a Subdivision provide Information,as follows: lriA,o G g Name: AA2C" U)o6Ds PAAz.E�/�qg Section: Block: Lot: 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 falstiled or changed. 1,also,understand that I anti responsible for all charges Incurred front this appUcadon. 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 sWtnbWft. DATE f� �� " q 9 SIGNATURE Z-�64------ 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 Notilicsflon Date: EAS: Account No. Revised DCHD(07/99) _ /Z- "� Invoice No. l , ✓ �� 3--7 o v 14fl' lw 8 40 moi Iz� II 1381 �1 rr {7D' / Zoc i r � f I DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900025 Tax PIN/EH#: 5789-76-5851.37 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#37 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre Date Evaluated: Cg Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position ,L Slope% /22 HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence r i Structure 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 SITE CLASSIFICATION: if EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: j !;✓ /,1 u�`✓e- / (/ EGEND 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) LIAR-Long-term acceptance rate-gal/day/ft2 DCHD 05/99(Revised)