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265 Old March Rd Lot 53 DAVIE COUNTY HEALTH DEPARTMENT G J Environmental Health Section 0 3 to 1� P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account M 989900025 Tax PIN/EH M 5789-79-5851.53 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#53 Reference Name: Location/Address: Old March Road-27006 Proposed Facility Residence Property Size: see map ATC Number: 4040 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: / 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. Septic System Installed By: Zq)- le Z4 Environmental Health Specialist's Signature:. ��// Date: "7,4,6 DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT / Environmental Health Section P.O.Boz 848/210 Hospital Street r Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900025 Tax PIN/EH#: 5789-79-5851.53 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#53 Reference Name: Location/Address: Old March Road-27006 Proposed Facility Residence Property Size: see map **NOR �ismprovement/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 Q-;� #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) 69(o 6 Site: New Repair❑ System Specifications: Tank Size 166h GAL. Pump Tank GAL. Trench Width,,—M Rock Depth.0/,gn) �Linear FtS. W Other: 18A.19659(5 usd Required Site Modifications/Conditions: accepted Systems may as IMPROVEMENT/OPERATION PERMIT LAYOUT: VED EFFLUENT FILTER RISERS)IF 6 u BELOW FINISHED GRADE. ****NOTICE: Contact a repres of the vie 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 m.on da f installation. Telephone#is(336)751-8760.**** ,ems Environmental Health Specialist's Signature: ��// Date: — t� DCHD 05/99(Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT& Davie County Health Department Envitnnme,7W Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 MAY 15 2002 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ATQC fApH INFORMATION IS PROVIDED. Refer to the INFORjMATION BULLETIN for instructmo 1. Name to be BilledDLIJST/ �,.L�r_ Contact Person ��/C/C ,(/�f/�l�d.l) Mailing Address p`Z,�� ,� ((/I,tJG 1&125 JLam/ Home Phone �/��- -7S7 / City/State/ZIP nwlestl��L r_ �,�. 70a Business Phone CJ CJS- -)-17 7 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: X Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: �(House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 1 5. If Residence: # People # Bedrooms 7 # Bathrooms LI Dishwasher L1 Garbage Disposal LI Washing Machine 11 Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City ❑ Well ❑ Community Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes IJ No If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQU TED \ BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. / 11 Property Dimensions: z % Ta (_Ori WRITE DIRECTIONS(from Moclzville)to PROPERTY: / Tax Office PIN: # 5"7 IS 9,7 q-SB 53 Property Address: Road Name UG/> 41/4/Zcoy /hoC�cs,/ictE �� J�l9dfloUCc 'A'v (fa/ City/Zip 40yAiJCr . 2700G Lt-A,— 41.) .tom If in a Subdivision provide information,as follows: TO 11JA,,c1q GUvo o s OAler-• Name: AlPer-N (iI,C 00-0, �5 3 Section: )"IA Block:N/•9 Lot: 53 Oate Property Flagged: �t��L O� //�p�tv 714 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 responsible for all charges incurred from this application. I,hereby,give consent to the Authorized Representative of the Davie County Hcalth 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 suita ' DATE �^ �a — O �. SIGNATURE 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). � Datc(s): Site Revisit Charge, Client Notification Date: �^ EHS: Account No. ` y 7 zoo S Revised DCHD(07/99) �` //_ S Invoice No. 0 0 1 w • ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account M 989900025 Tax PIN/EH#: 5789-79-5851.53 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#53 Reference Name: Location/Address: Old March Road-27006 Proposed Facility: Residence Property Size: see map Date Evaluated: Water Supply: On-Site Well Community Public !/ i Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope% HORIZON I DEPTH ell Texture group Consistence Structure Mineralogy HORIZON H DEPTH Texture group 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: 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 t 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)