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130 Oak Hill Rd Lot 71 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • ' P.O.Boa 848/210 Hospital Street Mocksviille,NC 27028 (336)751-8760 - IMPROVEMENT/OPERATION PERMIT Account M 989900025 Tax PIN/EH#: 5789-79-5851.71 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#71 Reference Name: Location/Address: Old March Road-27006 Proposed Facility: Residence Property Size: see map ATC Number: 3480 **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. r. Residential Specification: Building Type Ad #People #Bedrooms #Baths Dishwasher: 0""' 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) Site: New .Repair❑ System Specifications: Tank Size ICbD GAL. Pump Tank GAL. Trench Width Rock DepthLinear Ft � Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISERS) 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.m.on the day of installation. Telephone#is(336)751-8760.**** Environmental Health Specialist's Signature: GtN/ Date: DCHD 05/99(Revised) .> 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#: 5789-79-5851.71 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#71 Reference Name: Location/Address: Old March Road-27006 Proposed Facility: Residence Property Size: see map ATC Number: 3480 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,Sectior .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER C014 4ST,RUCTION IS VALID FOR A PERIOD,(O�FTIIVE YEARS. Environmental Health Specialist's Signature: �� %�'��- Date: !17 GvT Q,f, 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. r Septic System Installed By: Environmental Health Specialist's Signature: Date: .- DCHD 05/99(Revised) P.O. �;. .; APPLICATION FOR SITE EVALUATION/IMPKUVEMEM PERMIT 8c Davie County Health Department Q Environmental Health Section P.O. Box 848/210 Hospital Street A/AY Mocksville, NC 27028 ) 5 2002 + (336)751-8760 SEN t _ ***IrSPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL-TH QT(1� j u11T11 INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructio u 1. Name to be Billed Contact Person ��/6je 14AIe' Mailing Address iR,�.� .� C(�lAl G /YjL)�/f'�(/L�tyG� Home Phone `74%.a � - /1 City/State/ZIP /�' wle—s✓/C�_r_ �J,�. ..(70.2 Business Phone J 7S- 7 A 7 2. Name on Permit/ATC if Different than Above ` Mailing Address City/S ate/Zip X 3. Application For: Site Evaluation Improvement Permit/ATC II Both 4. System to Service: House ❑ Mobile Home ❑ Business ❑ Industry IJ Other 5. If Residence: # People # Bedrooms 7 11 Bathrooms 1.1 Dishwasher LI Garbage Disposal ll Washing Machine LI Basement/Plumbing II Basement/No Plumbing 6. If Businoss/Industry/Othor: Specify typo # People 0 Sinks _ # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: f) Seats Estimated Water Usage (gallons par day) —_ 7. Type of water supply: County/City ❑ Well I1 Co.nununity Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes I:I No If yes,what type? ***Id1PORTANT***CLIENTS MUSTCOMPLLTETHE REQUIRED PROPERTY INFORMATION REQI1 5S'1'EQ i BELOW. Eithcr a PLAT or SITE PLAN AIUSTBESUBAlITTED by the client witl►THIS APPLICATION. �G � -��'—.�;-tl/sJk f f Properly Dimensions: �% 7-o WRITE DIRECTIONS(from A•locicsvillc) (o PItUI'ICitTY: Tax Office PIN: # S-7 0- -7-7-7-ST S-) ,-I _ Property Address: Road Name OGe) AlAlzCa/ -leo mo4esylLe- /-0 Ae9d,9oUCc .//W -a City/Zip 40V1-7.,UC1f. 2700( LF,ci•- eA) If in a Subdivision provide information,as follows: TZ► 1nA,,2C/-j LC/oo� oy 2r Name: _ _/G'I r4 e-c f-1 trt bo as �5 Section: /V/Block: /►'4 Lot: ( I Date Property Flagged: l(lci=!l O ��/� 71-1 This is to certify that the information provided is correct to the best of my knowledge. 1 understand that any permits) 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 atu responsible for all charges incurred.jrn►a this application. 1,hereby,give consent to the Authorized Representative of the Davic County Health Dcp:u•hucnt 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 �^ tc — O �. SIGNATURE •l /�)_ `�'^ 0��,2 - 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): j Client Notification Date::,. EHS: Account No. ��ooa -2- S Revised DCHD(07/99) � Invoice No. r ~ - DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900025 Tax PIN/EH#: 5789-79-5851.71 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#71 Reference Name: Location/Address: Old March Road-27006 Proposed Facility: Residence Property Size: see map Date Evaluated: D 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% i 4 HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH << Texture groupG' Consistence Structure ! iC 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: Ga 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 05/99(Revised)