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299 Old March Rd Lot 56 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 989900025 Tax PIN/EH#: 5789-79-5851.56 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#56 Reference Name: Location/Address: Old March Road-27006 ,�� Proposed Facility Residence Property Size: see map ATC Number: 3877 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: 4 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. A g y Septic System Installed By: !i Environmental Health Specialist's Signature: �' �/ Date: DCHD 05/99(Revised) DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900025 Tax PIN/EH M 5789-79-5851.56 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#56 Reference Name: Location/Address: Old March Road-27006 Proposed Facility Residence Property Size: see map ATC f�imlier: 3877 **NOTE** is mprovement/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 oLr S Dishwasher:.ee Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #S 13//eats Industrial Waste: Lot Size Type Water Supply 1 .0 Design Wastewater Flow(GPD),--W Site: New Repair❑ System Specifications: Tank Size IDD GAL. Pump Tank GAL. Trench Width���Rock Depth A-- Linear Ft30d Other: Required Site Modifications/Conditions: INIPROVEIIIENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF 6 K BELOW FINISHED GRADE. ****NOTICE: Contact a represents 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 1:30 p.m.on the day o ' allation. Telephone#is(336)751-8760.**** Environmental Health Specialist's Signature: �7�I Date: DCHD 05/99(Revised) e ' �,. APPUCATION FOR SITE EVALUATION/IMPROVEMENT PERMIT& Davie County Health Department Envirwnmej7W Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 MAY 5 2002 (336)751-8760 EIVVj _ ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS AL iQ EAl1}I INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instrucntio 1. Name to be Billed /fL/C��'rAJ4�d,,/ _l 04 Si/ -Z c_ Contact Person Mailing Address .2 Q S O/l.0 G• /7�4c -z f C—/ Home Phone -7S-7 5j City/State/ZIP I�(,Y/G8t//LLr �,�. �` 70, ,E Business Phone cj 9S- -17 2. Name on Permit/ATC if Different than Above Mailing Address City/S242244/ermit/ATC p 3. Application For: X Site Evaluation �ImP 11 Both 4. System to Service: House 0 Mobile Home ❑ Business ❑ Industry ❑ Other 5. I£ Residence: # People # Bedrooms 7_ # Bathrooms 11 Dishwasher U Garbage Disposal CI Washing Machine U Basement/Plumbing 1] 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 0 Well El Community Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 1] No If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQU,&STED ` BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client witli THIS APPLICATION. /S 11 Property Dimensions: 34 w 4� C_vr WRITE DIRECTIONS(from Mocksville)to PROPERTY: / y - Tax Office PIN: # 5-7 0 y 7 9-S9 S1 � Property Address: Road Name 064 /%A,,-Ica/ A89 _ /'1'ioc/�s,/luE �� A94000C1tFFA-v y 'fa/ City/Zip 40V4,Ucr , 7.7006 L6A7- o,u C'e-ee-ie- .eo If in a Subdivision provide information,as follows: 7-6 o,y 2r• Name: Alk?-CH 6tbQ19S Section: 'r'IA Block:N/►g Lot: 4576 Oate Property Flagged: V 6174 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. 1,also,understand that 1 am responsible for all charges incurred froin 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 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 Date(s): Client Notification Date: EHS: Account No.. y�� 7 000 Revised DCHD(07/99) Invoice No. o a )�D DAVIE COUNTY HEALTH DEPARTMENT Y Environmental Health Section SoiVSite Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account M 989900025 Tax PIN/EH M 5789-79-5851.56 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#56 Reference Name: Location/Address: Old March Road-27009 Proposed Facility: Residence Property Size: see map Date Evaluated: Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit ; Cut FACTORS 2 3 4 5 6 7 Landscape position Slope% i/ <• '� HORIZON I DEPTH Texture group X, /I / Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence l' Structure G I t,` Mineralogy HORIZON III DEPTH Texture group Consistence Structure IV Mineralogy HORIZON IV DEPTH Texture groupC .j 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 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 1, 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) Davie County Health Department ��;8 I� Environmental Health Section , i P.O. Box 848 t #A„ 210 Hospital Street C� O U �'C Courier# : 09-40-06 1911 Mocksville, NC 27028 Phonc:(336) 753-6780 ON-SITE WASTEWATER CERTIFICATION Fax:(336)-753-1680 (Check One) Replacement Remodeling Reconnection Name: D Phone Number Ilk-71 (Home) 7qqlGl (/t c - Mailing Address: (Work) 1 UC27� Email Address:-71 /e Detailed Directions To Site: 1 Q o � a1 7 ��� �►� A�td hi OA) OdAtleek 1L-wd Property Address: Zj l /'`til?6 1 I �qD�o� �J c3�17 Please Fill In The Following Information About The EXIST '/ING Facility: Name System Installed Under: �1('k /�Ml ZZA) 401V51, Type Of Facility: Date System Installed(Month/Date/Year): 9004-1 Number Of Bedrooms:s6Number Of People: 3 Is The Facility Currently Vacant? Yes 0 If Yes,For How Long? Any Known Problems? Yes No If Yes,Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: P0SOX0� �l'JS�I itI G)' Cpl' 7'` Number Of Bedrooms: Number of People Pool Size: Garage Size: Other: �y Requested By: Date Requested: b 3' ( ' ature) For Environmental Health Office Use Only Approved. Disapproved Comm ts: Environmental Health Specialist Date: *The signing of this form by the Environmental Health Staf s in no way intended,nor should be taken as a guarantee (extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # Amount: Date: Paid By: Received By: Account#: Invoice#: