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238 Old March Rd Lot 63 .. DAVIE COUNTY HEALTH DEPARTMENT - Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account M 989900025 Tax PIN/EH#: 5789-79-5851.63 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#63 Reference Name: Location/Address: Old March Road-27006 Proposed Facility Residence Property Size: see map ATC Number: 4029 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 IVE YEARS. 'A Environmental Health Specialist's Signature: Date: �( 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. j ! r Septic System Installed By: Environmental Health Specialist's Signature: Date: a DCHD 05/99(Revised) f DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street M , � Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900025 Tax PIN/EH#: 5789-79-5851.63 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#63 Reference Name: Location/Address: Old March Road-27006 Proposed Facility Residence Property Size: see map ATC Number: 4029 **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 IV #People #Bedrooms #Baths Dishwasher: 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) �S4 49 Site: New❑ Repair❑ System Specifications: Tank Size/DDU GAL. Pump Tank GAL. Trench Width 21 Rock Depth f-2"'Linear Ft-OiJO Other: As stated in 15A NCAC 18A.19= ameged Sy MS maT11lRfl Imo * Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- PP EFFLUENT FILTER. RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representa ' o e 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. o stallation. Telephone#is(336)751-8760.**** _/ -j � Ss C� Environmental Health Specialist's Signature: ( 6 / Date: DCHD 05/99(Revised) APPLICATION FOR SITE EVALUATION/IMPIIOVEMENT PERMIT& Davie County Health Department Environmental Health Section P.O. -Box 848/210 Hospital Street Mocksville, NC 27028 M�Y ' S 2��2 (336)751-8760 ENVI _ ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESSAIM 0; G(TI/ _ INFORMATION IS PRROVIDED. Refer to the INFORMATION BULLETIN for inst-ructio 1. Name to be Billed ./lc%' 44tF.3y,0 I�.'04kSi -Z c'_ Contact Person Mailing Address i-;Z • (.CJ/,U(r- /Y- Zg A-J Z J Home Phone % — 7S'l City/State/ZIP /y/(xJGgt//L Lr_ �l.C. �` 74� Business Phone 57(f— 7.A 7 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: Site Evaluation ❑ Improvement Permit/ATC I'l Both 4. System to Service: House ❑ Mobile Home ❑ Business ❑ Industry U Other 5. If Residence: # People # Bedrooms x U Bathrooms LI Dishwasher LI Garbage Disposal LI Washing Machine U Basement/Plumbing Il Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People 11 Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City ❑ Well I:I Community Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes LI No If yes,what type? ***IMPORTANT***CLIENTS MUSTCOMPLETCTHE REQUIRED PROPERTY INI,ORMATION REQU S'11"D BELOW. Either a PLAT or SITE PLAN MUST BESUB4117TED by the dicnt with THIS APPLICATION. [G�i4 Property Dimensions: 7-0 WRITE DIRECTIONS(from A1ocicsvillc)to I'ROI'ER'I.1': Iq Tax Office PIN: # 5 7 0 `77 Property Address: Road Name 06/0 17JA1Zca/ 4 moc/cs✓Iu.E "-0 AJ'il'o"V czy./ V fb/ City/Zip 40VAivCr , 27004 LF,c,- If in a Subdivision provide information,as follows: Th /}1,4,,2C14 U1001jg OA)le;,-. Name: /VIv4i,?-04 6t bOPS P1-i43�' Scction: /� Block:N�►4 Lot: G 3 Date Property Flagged: 4)E;Flc O //)w ;;7-t This is to certify that the information provided is correct to the best of my knowledge. 1 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 clianged. I,also,understand that 1 ami responsible for all charges incurred f om this application. I, hereby,give consent to the Authorized Representative of the Davie County Health Depadnirn( to enter upon above described property located in Davie County and owned by _ to conduct all testing procedures as necessary to determine(lie site suita DATE SIGNATURE l /0_ � 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 Datc(s): Client Notification Date: JO/0 s EHS• f� V q Account No. / Invoice No. 0 Revised DCIiD(07/99) �O DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ' Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900025 Tax PIN/EH M 5789-79-5851.63 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#63 Reference Name: Location/Address: Old March Road-27006 Proposed Facility: Residence Property Size: see map Date Evaluated: Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape positionL-- Slope% HORIZON I DEPTH Texture groupL' Consistence Structure Mineralogy HORIZON II DEPTH Texture groupG Consistence 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: ti' EVALUATION BY: 5 l/ LONG-TERM ACCEPTANCE RATE: 1 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)