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238 March Ferry Rd Lot 38 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#: 5789-76-5851.38 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#38 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number: 2594 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 I 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER S UCTION IS VALID FO OD OF FIVE YEARS. r Environmental Health Specialist's Signature: � ate: le> 3 f3 i2c�mS 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 arantee that the system will function satisfactorily for any given period of time. ^ �tv qi Septic System Installed By: Environmental Health Specialist's Signature:. GL Date: DCHD 05/99(Revised) i i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900025 Tax PIN/EH M 5789-76-5851.38 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#38 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number: 2594 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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: Z Garbage Disposal: ❑ Washing Machine:0"*' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size j/l�G Type Water Supply Design Wastewater Flow(GPD) Site: New 12 Repair❑ a System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width,?rRock Depth�2V Linear Ft Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EF ENT FILTER. RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the unty 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 a day of installation. Telephone#is(336)751-8760.**** A Environmental Health Specialist's Signature: •Date: DCHD 05/99(Revised) APPLICATION FOR SITE EVAWATION/IMPROVEMENT PERMIT b ATC Davie County Health Department - Environments/Hen/M Sectfon D P.O. Bos 848/210 Hospital street d [; 7199 Hockaville, NC 27028 (336)751-8760 ***INPORTAHT*** %%Is APPLICATIoIi Cato= Aid BROCIsmm Ummo = M REQUIRED INM MATION Is PROVID,�E/D. Refer to the XMVIMATIOH BULLETIN forllinstructions. 1. Name to be stilled z Kle J4"'Oe- &6d•(i Aj s,7- contact Person Nailing Address AA5 LAI JA)e.e4A V" L N , some Phone WA- 7579 city/state/azP AlocleAyIt't..-", N. C. a 70AX swinesa Phos. 9q&- 7A7 f; Z. Name on P.rait/ATC it Different than Above Mailing Address City/state/sip `6 3. Application for: )<site Rvaluation ,,0�Improv-/6 - Permit-FATC 0 Both e. System to servioei House 0 Mobile Home 0 Business 0 Industry 0 Other S. If Residence: # People / Bedrooms )'YIDS 3 e Bathrooms Dishrasber T/Qarbage Disposal j NASUnD Machine 0 saswnt/Olssbiaq 0 sasament/No plumbing 6. If ansiness/Industry/Others apecify `typo # People i sults I Commodes # showers I Urinals i later Coolers IIP r=sERVIc=: # seats estimated Nater Usage tone Par aay) 7. Type of water supply: county/City 0 Well. 0 community 9. Do you anticipate additions or expansions of the faclilty this system Is Intended to serve? 0 Yes �No If yes,what type? ***IMPORTANT***CWENTS MUSTOOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BEI.AW. Either a PLAT or SITE PLAN MUSTBESUBMITTED by the client with THIS APPLICATION. Property Dimensions: AAVIW A A/_A A A WRITE D'ILRECTIONS(from MocW11e)to PROPERTY: Tax 08icePEN: N �Z SS�, 76 "S� II'3�) AN70 7-D SS0I70 PiL4P,,6a Property Address: Road Name ( "ISE/C — LEFT C/,) /n a Fz7 City/ZIP InAeM waS=33 If In a Subdivision provide Information,as follows: !Yl'A,D G g Name: IYUR-OX4 W odDs o04Az,&=-g Aqg Section: Block: Lots Date Property Flogged: 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 pians or Intended ase change,or If the information submitted In this application Is falsifkd or changed 1,also,understated that I an rMonsible for all charges 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 salta6 . DATE 1A 4 " 9 9 SIGNATURE 6JZ,64�44� 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 Notifleadon Date: ERS: -� Account No. a.2� Revised DCHD(07/99) Invoice No. 3 „7cA —Q o r ti0 (r•G 14'D l4n' g 40 v Y 120• 12$ II 1 X41`. Lb' 34 120' 00' 1381 _ / J 1 � • Z� Og` {7d r x F ti:• - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900025 TaxPIN/EH#: 5789-76-5851.38 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#38 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre Date Evaluated: 06 Water Supply: On-Site Well Community Public t� Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope% HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence 9/ . Structure Mineralo 4" 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: y EVALUATION BY: l LONG-TERM ACCEPTANCE RATE: f I OTHER(S)PRESENT: REMARKS: �C ��' 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 oist 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 Mineraloev 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)