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294 Old March Rd Lot 57 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 ILI r Account M 989900025 Tax PIN/EH M 5789-79-5851.57 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#57 Reference Name: Location/Address: Old March Road-27006 Proposed Facility Residence Property Size: see map ATC Number: 4118 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 CONSTR CT ON IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: � YDd 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 I 1 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. t � tT� P' k S "C STD V F-2eJT Septic System Installed By: '--' �a � '1�^t Environmental Health Specialist's Signature I ate: ^ ✓ DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT p • Environmental Health Section P.O.Boa 848/210 Hospital Street ' Mocksville,NC 27028 (336)751-8760 1 IMPROVEMENT/OPERATION PERMIT Account M 989900025 Tax PIN/EH#: 5789-79-5851.57 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#57 Reference Name: Location/Address: Old March Road-27006 Proposed Facility Residence Property Size: see map ATC Nurpber. 4118 **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 & . #People #Bedrooms #Baths`2 Dishwasher: Garbage Disposal: ❑ Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift ##Seats Industtrial13Waste: Lot Size Type Water Supply Design Wastewater Flow(GPD) `S�� Site: New Z lWRepair❑ System Specifications: Tank Size GAL. Pump Tank`dN>GAL. Trench Width,- Rock Depth/,j cLinear Ft4? Other: As stated In 15A NCAC 18A.198 Required Site Modifications/Conditions: Oceepted Stems malalso-ba-U"'U 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.m7ontheda dastallation. Telephone#is(336)751-8760.**** Environmental Health Specialist's Signature: Date: IaAz� DCHD 05/99(Revised) j.. • �.f._a• - Z�•-o Z APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT& Q Davie County Health Department Environmenfa/Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 MAY 15 2042 (336)751-8760 FNVI ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALS 011TH INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instru�c/Its 1. Name to be Billed %lC/c' s�.11�Jr d,V / 0AtS7- -Ly c_ Contact Person Mailing Address rR a J abAl(r. 1&/��ZX-) Home Phone yam- 79 City/State/ZIP , /�JGSIJ/LLr_ �,�, 70„� f Business Phone 5 IS- -)-17 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: X Site Evaluation ❑ Improvement Permit/ATC [I Both 4. System to service: �(House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms -23 _ # Bathrooms D /-I'- 1.1 -I/I:I Dishwasher ❑ Garbage Disposal CI Washing Machine U Basement/Plumbing f.l Basement/Ito 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 ❑ No If yes,what type? ***IIIIPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQU TED \ BELOW. Either a PLAT or SITE PLAN AfUST BESUBMITTED by the client with TIIIS APPLICATION. �4 () S 1` 5,j Ply Property Dimensions: �/ -0 .tICl2F CdT� WRITE DIRECTIONS(from Mocloville)to PROPER'T'Y: / Tax Office PIN: # 5'7 0 `7,71,5 -) ,5 Property Address: Road Name OG/P /11,42cay /2o /'h0 w�c �� dflouCc ;.may_ 'fe,/ City/Zip 40VIIIUCr= , .2-7004 LEA,— oAJ 'eo (/) ,,,/C.4 If in a Subdivision provide information,as follows: Th MAI-KCR U10612,5U10612,50,1)-e,-- Name: Ad PeC/-) tiI.0 op- Section: /l4 Block: Lot: s-`7 Date Property Flagged: 14) O/-- //gypV 6 174 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 Mat I ant responsible for all charges incurred frau 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 suits DATE �^ �o — Doti 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). Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. ��y aoo -2- S Revised DCHD(07/99) Invoice No. a DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • SoiVSite Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account M 989900025 Tax PIN/EH M 5789-79-5851.57 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#57 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 i/ Cut FACTORS 3 4 5 6 7 Landscape position Slope% Jell HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence 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: '��< EVALUATION BY: LONG-TERM ACCEPTANCE RATES: / OTHER(S)PRESENT: REMARKS: �nf 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)