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133 Oak Hill Rd Lot 69 DAME COUNTY HEALTH DEPARTMENT .+ • Environmental Health Section P.O.Boz 848/210 Hospital Street =� Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900025 Tax PIN/EH#: 5789-79-5851.69 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#69 Reference Name: Location/Address: Old March Road-27006 Proposed Facility: Residence Property Size: see map **NOTL�* Ib gmprovement/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: ;T" Garbage Disposal: ❑ Washing Machine-;2**' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type /J #People #People/Shift #Seats Industtrriall Waste: ❑ Lot Size Type Water Supply C l3 Design Wastewater Flow(GPD) Site: New Repair❑ System Specifications: Tank Sizel_�&GAL. Pump Tank GAL. Trench Width L?6�'� Rock Depth j9 Linear Ft,T� Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6 K 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.**** / 7 J.- Environmental Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT t Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 989900025 Tax PIN/EH#: 5789-79-5851.69 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#69 Reference Name: Location/Address: Old March Road-27006 Proposed Facility: Residence Property Size: see map ATC Number: 3424 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 CO,N�(STRRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: X-V / 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. -;::; 6 iL��a1C3 a y Septic System Installed By: Environmental Health Specialist's Signature: L�V��/ Date: "1(5-� DCHD 05/99(Revised) APPLICATION FOR SITE EVALUATION/IMPROVE&IENT PER&IIT& ( j� Davie County Health Department L/ L; Q Environmental Health Section P.O. Box 848/210 Hospital Street A/AY Mocksville, NC 27028 + (336)751-8760 ***I1%JPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS AL-L-TR �PiL1 b 1( t�ll(I �' INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions,-�� n �f /� 1. Name to be Billed ,%/Oc fl�4��0,t)/ ( 0,4-1S!/ -Z r_ Contact' Person Mailing Address Z,-? Q � al iAl G- /7'FQj/ Home Phone -7,51-7 City/State/ZIP !'YlGB✓/fir_ �/,(!. 70,Z �' Business Phone f qS— 7 7 _ 2. Name on Permit/ATC if Different than Above Hailing Address City/State/Zip _ 3. Application For: X Site Evaluation ❑ Improvement Permit/ATC II Both 4. system to service: i(House ❑ Mobile Home ❑ Business ❑ Industry IJ Other 5. If Residence: # People Bedrooms ! it Bathrooms 1.1 Dishwasher ll Garbage Disposal U Hashing Machine L1 Basement/Plumbing II Basement/No Plumbing 6. If Business/Industry/Othor: Specify type 9 People It Sinks I Commodes # Showers 9 Urinals tt Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City ❑ Well I1 Community Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes is No If yes,what type? ***IMPORTANT***CLIENTS MUSTCOMPLLTETHE REQUIRED PROPER'T'Y INFORMATION REQU �STED t BELOW. Either a PLAT or SITE PLAN MUSTBESUBAMMD by the client witli THIS APPLICA'T'ION. Gl a f Property Dimensions: �31 7-0 WRITE DIRECTIONS(from Nlochsvillc) to PROPERTY: y Tax Office PIN: # 6-7 0- -7-7 2LST �) Property Address: Road Name OG/� /1?/g2ca/ /-2 mogesvlc-CC /-0 44911'louC'c" Jlw _a City/Zip 4011A ic4 , :2 7006 LF,cr e>N i cE If in a Subdivision provide information,as follows: TL 0A)2r Name: �'1�{�2C/-t' �C��S ✓�-i�3�" Section: '�J/t4 Block: �►4 Lot: Date Property Flagged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any 1wrmil(s) issued hereafter arc 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,ruulerstand that 1 aur responsible for all charges inc•ar•red.%ruru 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 �^ �a — O o1. 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): Client Notification Date: EIIS: Account No. ODO S Revised DCIID(07199) `d 4D Invoice No. s C� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900025 Tax PIN/EH M 5789-79-5851.69 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#69 Reference Name: Location/Address: Old March Road-27006 Proposed Facility: Residence Property Size: see map Date Evaluated: Water Supply: On-Site Well Community Public +fir Evaluation By: Auger Boring Pit — ( Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope% HORIZON I DEPTH Texture groupL?G Consistence Structure Mineralogy HORIZON II DEPTH '� v Texture group Consistence 77 Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION 4 LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: i LONG-TERM ACCEPTANCE RATE: r' 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 MineraloQv 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)