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295 Old March Rd Lot 55 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#: 5789-79-5851.55 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#55 Reference Name: Location/Address: Old March Road-27006 1��7 Proposed Facility Residence Property Size: see ma ATC Number: 3759 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 CONS ION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: 4 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 S ems,"but shall in NO WAY be W= tee that the system will function satisfactorily for any given period ft time. -�v a cIx /gyp 7oVh L F Septic System Installed By: ),qL� Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) r • DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 A—, --Cly (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 989900025 Tax PIN/EH M 5789-79-5851.55 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#55 Reference Name: Location/Address: Old March Road-27006 Proposed Facility Residence Property Size: see map ATC Number: 3759 **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 Y," 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 C'/ Design Wastewater Flow(GPD) Site: New❑ Repair CI /l System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width Rock Depth �2: Linear FtZ�'Po Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- A UENT FILTER. RISER(S)IF 6 K BELOW FINISHED GRADE. ** NOTICE: Contact a representatj a Coun h Department for final inspection of this system between 8:30 a.m. 9:30 a.m.or 1:00 p.m.to 1:30 p. on the da of ins one#is(336)751-8760.**** d� ),,g(,tj h-1let- deT Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) �,. APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT& Davie County Health Department 0 Envinvnmenta/Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 MAY 5 2002 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS I , EALTH INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instrulctxo �/.lJ 1. Name to be Billed 2216le /)t2�d,L) r OA)Si -Z c_ contact Person ��/U � e�f(/ Ll _ r _ Mailing Address 5? Q 5 al i l(r- AlAt/6�Z-.,,O Home Phone -73 7 City/State/ZIP - Business Phone C JS - 7.A7 7 2. Name on Permit/ATC if Different than Above Mailing Address City/Sta 3 Application For: Site Evaluation ro�ement Permit ATC fl Both APP � Imp Permit/ ATC System to Service: 1&ouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 1 5. If Residence: # People # Bedrooms 7 # Bathrooms D LI Dishwasher U Garbage Disposal LI Washing Machine . U Basement/Plumbing 11 Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People 4 Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City ❑ Well LI Community Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes LJ No If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUYSTED BELOW. Either a PLAT or SITE PLAN MUST BESUB111ITTED by the client with THIS APPLICATION. a /SII Property Dimensions: TO WRITE DIRECTIONS(from Modisville)to PROPERTY: Tax Office PIN: # 51 , �5 Property Address: Road Name 060 4J,,42ca/ leo rAwy fa! City/Zip 40VA'uCr , 27004 LEAr e-u �.=o/� _ ��ic (/)oy!/cmc If in a SubdivisiontiL, provide information, Tl ation,as follows: InAi2C V GG/o06 115r 0 )2 • Name: 44t4kecm boos Section: P'//4 Block:N�,�} Lot: Date Property Flagged: 4) 194 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. 1,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 suita DATE 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 Datc(s): Cli cut Notification Date: -� •�/ v EHS: Account No. �� 100o Z Revised DCHD(07/99) Invoice No. 0J- ' C cL • , . ` ; DAVE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900025 Tax PIN/EH#: 5789-79-5851.55 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#55 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 1 2 3 4 5 6 7 Landscape position L Slope% HORIZON I DEPTH101 // 4L Texture group .5G Consistence Structure Mineralogy HORIZON II 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 G LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: 6 EVALUATION BY: LONG-TERM ACCEPTANCE RATE: i THER(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-Finn 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) i i i ' r i , � I ,i i t; I r I 1 I LC ��. `0 , jL NrsPN c � �