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118 Maple Valley Rd Lot 25 •. l Davie County Health Department AN% Environmental Health Section km P.O.Box 8488 0", . AAZD 210 Hospital Street ae i 3' () 'L a (3 Courier#:09-40-06 Phone:(336)-753-6780 vK• �l Z Fax:(336)-751-8786 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection /� /� 6-7( —1/4 `f Name: Vick AND,� 81 o IU L.6 AAT Phone Number 3 9 6 !!/22 ZCZ Y (Home) Mailing Address: 2-2tffl t Ad ei UAs N ke -3% lik I,? 7f (Work) EmailR Detailed Directions To Site: 1 10 E, 4x/r 4( �, �T e to Pie PL- �S CRF E K_ Rr a tJ 6 Lb MAL AT Al s Property Address: b' Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under:_ _A lam/ CJe-'t4,o,5 Type Of Facility: USE Date System Installed(Month/Date/Year): 0�0 0(P Number Of Bedrooms:_ Number Of People: 03 Is The Facility Currently Vacant? Yes No If Yes,For How Long? Any Known Problems? Yes No If Yes,Explain: IV�O M CA604t Pr 9S--- Vr-LN£S Tb Please Fill In The Following Information About The 1VEA'FaciLty:,y�q 5�,E-771EYA26 Cter,S�1I�oA& Type Of Facility: _ Number Of Bedrooms: of People `-QC'-'F Requested By: Date Requested: (Signature) For Environmental Health Office Use Only Appr Disapproved ��II (_ r Comments: /vv/Q J i b Environmental Health Specialist Date: *The signing of this form by the Environmental Health Staff is in no way intended,nor s ou a 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#: l7 tootL o Invoice#: a 7 ' Li TO � q i ! 1 9 � E t y .5'6 RO w y DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990002285 Tax PIN/EH#: 5789-97-0344.25 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Phase 4 Lot#25 Reference Name: Location/Address: Peoples Creek Rd.-27006 ATC Number: 4442 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 WASTEWATE O S C O IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: 2 As stated in 15A NCAC 18A.1969(5) accepted Systems may also be usedd 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 Syst s,"but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. �a P r; Septic System Installed By: Environmental Health Specialist's Signature: r L� Date: DCHD 05/99(Revised) • DAVIE COUNTY HEALTH DEPARTMENT . ; Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 �1 IMPROVEMENT/OPERATION PERMIT Account #: 990002285 Tax PIN/EH#: 5789-97-0344.25 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Phase 4 Lot#25 Reference Name: Location/Address: Peoples Creek Rd.-27006 Proposed Facility: Residence Property Size: see map ATC Number: 4442 **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 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) 6O Site: New Repair❑ System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width,.,�Rock Depth Linear FtPb Other: As stated in 15A NCAC 18A.1969(5) Required Site Modifications/Conditions: accepted Systems may also be usetls IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6 i°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.m.on th day f insta Telephone#is(336)751-8760.**** Ib rat i , 6 5 Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) $�b4 1� v 4wQ 'GO-UJ-VL ; -TJ(•+ ......�NLt:n rinUt9t'5Uf1 --- •-- -. -- ,7J9 .71.10 tGts7 APPLICA110M EOR SITE EYAUXTION/1111PROVE14E IT PERMIT&ATG 'Davie Cpynty Health Departrnent n 'Envltvnm,Itrbl Hca/t!r Sibn L-• P.O. Box 868/210 Hospital Street pfocJcavi 334, NC 27421 (3363751-8760 ewwSMDORTANTwwe THIS A VLXC&TION CAM=BE PROCESSM MM=S ALL TH8 ==RED IHFORDIATIOA XS YRDVM=. Refer to the IIQFOHa1=OX XULLStIN for Instructions. ✓3. eras. to be sill.d„ / .Y8i904c!!j5&d COVSI-ZA1( comtect ser— D161GhL`N /!�'.SdA) a/liaiii.g Afdreas � z6y,14A �I� C.,W s shone q 7�--2J�7 ✓cit?/aute/za /l�At hS J/C�.E JII. 2707.8 ✓amines.shone q IS-7a.7q Pta.r eo ►enate/ATC if •rent then Above tlatltoq addrw Ci.r/state/zip -1. Application Fora 95its evaluation ❑Iatprovament permit/ATC 0 Both ,,tet. ey.%—to seevlse.XUouae 0 Mobile Uoee 0 susiHess .CI industry 13 other .--i. Type.yatc..regoeatod. 0 Co *Atloaal C3 eoo•"tioaal codified Q laawuiw --c. .I.f/R/esidences s poopla I Hedrocane _ s Batbrooms -� IODISIweber t50.rbrge Olepenal aahip BaaW. ❑sou.+Vrlusbteq Osuwet/ne piucbiwq 7. It susleeae/Iodmtry/otb.r, verify type a people I Stake I cc-wdas a£asses ■Drlsala s Matter Caelare IP FOODSERVICE: 11�Sagtt• =L-taimgt-d water 199uSe. Sstlliana i-r M•) --a. Type of Water supply, G Coua:y/City 13 Hell 0 C0.bmunit , f. Do yam anticipat.additiods or expansions of the facility this system is inteardod to serve?(3 Yes cro Ifycs.trhatt L0?0JZ RN7`i1CLlr4frdbIUSTCO ptenTHE REQUIRED PROPERTY woitMATIONREQUESTED eE. UrheraPLAT orSRGPL rYr8ES1l8NI7yEDb tbedtmt with THIS APPLICATION. L--'Yroperty Dimensions: S Ss Et%--WRITEDIAELTtONS(from m"ksvm)to PROPERTY: i -Tax orrft rev: a W9 3 CA V 158 M X0 s r-2�6Pccss C-ze--- _—PropertyAddrts+: Read Name Cityrap VA,.,Cc- AJrj7ozr fin a Subdividon rovlde intormatiin,as fallokvs: Nome: /Mi}/zcp"nes C- A MS4 4 Section: Black: Lor. � &-Irate home Corners IhZeed: 15,196Cr262 IC6C 142e&/J6'cg This is to cert(ty,that the information provided is correct to the best of my knowledge.I understand that any I)CMIU(S) issued hereafter are subject to suspension orfevotot(on,If the site plans or intended use change,or it the inrorntation submitted In this application is falsiried or chasm-l.I•also,up4asrand t/,arI a,a regw-mtWerm.elf eLprges incurred from this applicadom 11,hereby,give•orient to the Authorized Relirtsentative of the Davie County harsh Dcpartsnrat to enter upon above described propertr located in Davie County and o,vned by to conduct all testing procedures as acc=&:ry to determine the site sus L-�DATX .2-A 3- o S SrcrATURE THIS AREA MAYBE USED FOR DRAWING YOUR SITS PLAN(Include a0 of the rellowing: Exutitt=and proposed property lines and dimensions,structures.setbacks, and septic locations). Site Revisit Cturtc Date($): Client Notification Date- EHS: Sign given hzAccount No. 4g�qoaa,57 Revised DCHD(QS/tt3 Invoice Na . ED DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPI,ICA*pqM% 85 Tax PIN/EH#: WftJ9FjW4IWORMATION c: .Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Phase 4 Lot#;R9_ ' Reference Name: Location/Address: Peoples Creek Rd.-27006 Proposed Facility: Residence Property Size: see map Date Evaluated: Water Supply: On-Site Well i Community Public Evaluation By: Auger Boring Pit Cut FACTORS ! 2 3 4 5 6 7 Landscape position Sloe% HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence - Structure Mineralogy HORIZON III DEPTH Texturegroup 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 is 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 Strudure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prisrpatic 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) LTA.R-Long-term acceptance rate-gal/day/112 _ •. ' i- DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION_ LOT ' Soil/Site Evaluation APPLICANT'S NAME � 1�D'1 DATE EVALUATED_ c� AS J PROPOSED FACILITY PROPERTY SIZE SUBDIVISION ��J�.C�✓o4�'-�"��C �� ROAD NAME Water Supply: On-Site Well Community Public t/ Evaluation By: Auger Boring Pit l Cut JA FACTORS 1 2 3 4 5 6 7 Landscape position Slope% HORIZON I DEPTH 61/ Texture groupSCG Consistence ,. Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure , 7 Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION _775- 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 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(O1-90)