148 Maple Valley Rd Lot 22 f OPERATION PERMIT FCD
r ice se Only
Davie County Health Department le Number 189$29-1,,v
210 Hospital Street
P.O. Box 848 D Number.
Mocksville NC 2702$ Evaluated For. EXPANSION
Phone:336-753-6780 Fax:336-753-1680 Township:
Applicant: Dick Anderson Construction Property Owner: Douglas and Jennifer Hanes
- Address: -225 Wnig Haven Lane Address: 148 Maplevalley Rd
City: Advance. City: Advance
- -•State2ip: NC . 27006 'statetzip: NC 27006
Phone#: (336)998-7279 Phone#:
Property Location & Site Information
Address/Road#: Subdivision:- Marchwoods Phase: Lot: 22
148 Maplevalley Rd
-
----Advance NC 27006 Directions
Off Hwy 801 South, People Creek Rd. Marchwood
Structure - SINGLE FAMILY P
Subdivision
#of Bedrooms: 4
#of People:
*Water Supply: PUBLIC
`*IP Issued by. 21ao Natioris,Robert *System Classification/Description:
'TYPE III G.OTHER NON-CONN.TRENCH SYSTEMS
*CA issued by: 2140-Nations,Robert
_ SaproliteSystem? OYes ONo
Design Flow: _ = 1" 2 0 GRAVITY-SERIAL Pump Required?
Distribution Type: Oyes QNo
Soil Application Rate: 0 2 7 5 *pre Treatment:
Drain field
N cation Field 4 3 6 Sq.ft. *System Type: INFILTRATOR QUICK 4 STANDARD
No. Drain Lines a Installer: Donnie Lakey
Total Trench Length: 1 1 0 g• Certification#: 1108
Trench Spacing: — 9 Inches O.C.
• Feet O.C. *EH S: 2140-Nation.Robert
Trench Width: 3 Inches
gFeet Date: 0 2 / 1 8 j 2 0 1 6
Aggregate Depth: inches
Minimum Trench Depth: 3 6
Inches
2.
Minimum Soil Cover. 4Inches Approval Status;/
Maximum Trench Depth: 3 6 ®:Approved O Disapproved
Inches
Maximum Soil Cover. 2 4 Inches
CDP File Number 199829 - 1 County ID Number: ?
Septic Tank
CMaacturer._ Lat.
Long:
STB:
Gallons: Installer
Date: Certification#:
*EH S:
*Filter Brand:
ST Marker. ❑ Yes ElNo _
Date:
(77
Reinforced Tank:
El
❑ No ApprovaI'S
fatus
=❑ Approved❑ Dis pproved
1 Piece Tank: ❑ Yes - ❑ No
Pump Tank
rManufacturer. Installer.
_ PT. Certification#:
i
Gallons: *ENS:
Date:
Date:
RiserSeaied ❑ Yes ❑ No
RiserHeghf: ❑ _Yes El (min. in.) A rovaiStatus
Reinforced Tank: ❑ -Yes ❑ No PP
O Approved❑ Disapproved.
1 Piece Tank: ❑ Yes _ .._ ._. El NoIRS iW
Supply Line
Pipe Size: inch diameter installer:
Pipe Length: feet Certification#:
*Schedule: 'ENS:
Pressure Rated ❑ Yes ❑ No Date:
Approved fittings ❑ �YeS ;_- - ❑ No Appimval Status
- : ❑ Approved❑ Disapproved
Requirement
Pump Type: Installer.
Dosing Volume: — Gal Certification#:
Draw Down: Inches *EHS:
-Cham:
Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ N o
Check-valve ❑ Yes ❑ N0Approv d8tatus
PVC unions ❑ Yes ❑ NoO Approved O Disapproved
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole 0 Yes ❑ No
CDP Fite Number 199829 - 1 County ID Number:
Electric Equipment
N EMA 4X Box or Equivalent ❑ Yes ❑ NO Installer.
_ Box 12 inches Above Grade ❑ Yes ❑ NO Certification#:
Box Adj.To Pump Tank ❑ Yes ❑ NO
Conduit Sealed ❑ Yes ❑ No THS:
Pump Manually Operable ❑ Yes ❑ NO
*Activation Method: Date:
;Approval Status
Alarm Audible- ❑`Yes - _ ❑ No -
- ❑ Approved❑ Disapproved„
Alarm Visible ❑ Yes ❑ NO
2140-Nations,Robert
_..,_.__"Operation Permit completed by:
y _Authorized State Agent - Date of Issue: 0 a a 4 j a 0 1 fi
Signature:
_
This-.system has been installed-in compliance with applicable NC General Statutes:Article 11, Chapter 130A, Rules'for
Sewage Treatment and Disposal,15A NCAC 18A.1900 et. Seq.,and all conditions of the Improvement Permit and,
Construction Authorization.This property is served by a TYPE ul G. sewage septic system.
-- - Rule A 961 requires that a Type �'E 111 G septic system meet the following criteria:
Minimum System Review By The Local Health Department: NIA
Management Entity:
OWNER
- .__Minimum System InspectionlMaintenance Frequency By Certified Operator: --
NIA
Reporting Frequency By Certified Operator:NIA
Rule .1961 requires that a.Type,IV:and Vsoptic systems designed for a home/business owner must maintain a valid contract__ _
--with a public'management entity with a certified operator or a private certified operator for the life of the septic system.
Rule.1961 requires that Type VI septic systems designed for a home/business owner must maintain a valid contract with a
- public management entity with a certified operator for the life of the septic system.
Rule. 1961 (2)(e)requires a contract shall be executed between the system owner and a management entity prior to the
issuance of an Operation Permit for a system required to be maintained by a public or private management entity,unless the
system owner and certified operator are the same. The contract shall require specific requirements for maintenance and
operation, responsibilities of the owner and systems operator,provisions that the contract shall be in effect for as long as the
system is in use,and other requirements for the continued proper performance of the system. It shall also be a condition of
the Operation Permit that subsequent owners of the systems execute such a contract.
BHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT 199825:^,l ,
Davie County Health Department CDP File Number:
210 Hospital Street
P.O.Box Bas County File Number: _
Mocksville NC 27028 Date:
Olnch
o- Scale: OBlock = . .ft.
Drawing Drawing Type: Operation Permit - ON/A
I I I I I I I f I I I I l I ( !
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CONSTRUCTION For Office Use Onlv
AUTHORIZATION *CDP Fite Number 199829-'1
Davie County Health Department County ID Number.
210 Hospital Street Evaluated For., EXPANSION
.� ,,. P.O.Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 0 a / 0 8 / a 0 a 1
Applicant: Dick Anderson Construction Property Owner. Douglas and Jennifer Hanes
Address: 225 Wnig Haven Lane Address: 148 Maplevalley Rd
City: Advance City: Advance
State/Zip: NC 27006 State0p: NC 27006
Phone#: (336)998-7279 Phone#:
Property Location & Site information
Address/Road#: Subdivision: Marchwoods Phase: Lot: 22
148 Maplevalley Rd
Advance NC 27006 Directions
Structure: SINGLE FAMILY Off Hwy 801 South, People Creek Rd. Marchwood
Subdivision
#of Bedrooms: 4
#of People:
"Water Supply: PUBLIC
System Specifications
Minimum Trench Depth: a 4
Site Classification: Provisionally Suitable Inches
Minimum Soil Cover. 1 a
Saprolite System? OYes *No Inches
Design Flow: 4 8 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 2 7 5 Maximum Soil Cover: a 4 Inches
*System Classification/Description: *Distribution Type: GRAVITY-SERIAL
TYPE II A CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
Gallons
"Proposed System: 25%REDUCTION 1-Piece: Oyes 0N
Pump Required: OYes ONo 0May Be Required
N krification Field
1 7 4 5
Sq.ft. Pump Tank: Gallons
No..Drain Lines. 1 1-Piece:OYes ONo
Total Trench Length: 1 1 0 8, GPM vs— ft. TDH
Trench Spacing: 9 @Feet O.C.Inches O.C. Dosing Volume: Gallons
Trench Width: _ 3 21riches
Feet Grease Trap: Gallons
Aggregate Depth: -
inches Pre Treatment: ONSF OTS-1 OTS-11
SepticTenk InstallerGrade Level Required: '01 011 0111 OIV`
Dann 4 of Z
CDP File Number 199829 - 1 County ID Number.
❑ Open Pump System Sheet
Repair System Required:.@Yes ONO ONO, but has Available Space
eaair System
Trench Spacing: � Inches . .
*Site Classification: Provisionally Suitable Feet .C.
Trench Width: Peet-00
chs
Design Flow: 48 0 — 3
Soil Application Rate: 0 - a 7 5 Aggregate Depth: inches
*System Classification/Description: Minimum Trench Depth: a 4 Inches
TYPE IIA.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover 1 Inches'
Maximum Trench Depth: 3 6
*Proposed System: Inches
Nitrification Field 1 7 4 5 Sq.ft. Maximum Soil Cover: a 4 Inches
No. Drain Lines 4 *Distribution Type: GRAVITY-SERIAL
TotalTrench Length: 4 3 6 Pump Required: OYes @No OMay Be RB4uired
Pre Treatment: ONSF OTS-1 OTS-II
*Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health,_Department.
"Permit Conditions
The issuance of this permit bythe Health Department in no wayguarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements. ;
This Authorization for Wastewater System Construction shall be valid fora person equal to the period of validity of the improvement Permit,not
to exceed five years,and may be issued atthe samatime the Improvement Permit issued(NCGS 130A-336(11)}If theinstallation has not been
completed during the period of wlidity of the Constriction Permit,the information submitted in the application for a permit or Construction
Authorization Is found to have been incorrect,falsified or changed,or the site Is altered,the permit or Construction Authorization shall become
Invalid,and may be suspended or revoked(.1937(g)).The person owning or controlling the system shall be responsible for assuring compliance,
with the laws,rules,and permit conditions regarding system'location;Installation,operation,maintenance,monitoring,reporting and repair
(1934b)):
Applicant(Legal Reps.Signature Required? Oyes ONO
Applicant/Legal Reps.Signature: Date:
*Issued By: 2140-Nations,Robert Date of Issue: . 0 2 . 0 .8 , , 2 6 1 6
Authorized State°i )nt c .. Malfunction Log Oyes
��
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department CDP File Number: 199829 - 1
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 02 / 08 / x 0 16
Q Inch
Drawin Drawing Type: Construction Authorization. Scale: . (OBbck .ft.
Q N/A
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CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street CDP File Number; 199829- 1
P.O.Box 848
Mocksville NC 27028 County File Number.
Date: 02 / 08laalb
Glick below to import an image from an external location: Drawing Type:Construction Authorization
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC
Davie County Environmental Health
P.O.Box 848/210 Hospital Street /
Mocksville,NC 27028
A_�d
(336)753-6780/Fax(336)753-16880
Application For: 7 Site Evaluation/Improvement Permit C Authoragpion To Construct(ATC) ❑Both
Type of Application: ❑New System ❑Repair to Existing System D ansion/Modification of Existing System or Facility
***IMPORTANT***THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
r `1 t
Name Q Sd/V �iutfiN Contact Person
Address Home Phone
City/State/Z Business Phone -
Email Email: y�
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged Q
NOTE: A survey plat or site plan must accompany this application. Included:U Site Plan UPlat(to scale)
(Permit is valid r 60 months with site plan,no expiration with complete plat.)
Owner's Name t�' Phone Number p
Owner's Address _City/State/Zip lv
Property Address fan City
Lot Size �+I Tax PIN#
Subdivision Name(if applicable) Section/Lot#
Directions To Site:
If the answer to any of the following questions is"Yes",supportinglooc—entation must be attached: /a
Are there any existing wastewater systems on the site? -'Yes Noo
_
Does the site contain jurisdictional wetlands? Yes 1I o
Are there any easements or right-of-ways on the site? _ es 'No /
Is the site subject to approval by another public agency? _Yes Z
Will wastewater other than domestic sewage be generated? —Yes—
IF RESIDENCE FILL OUT THE BOX OW
#People #Bedrooms #Bathrooms Garden Tub/Whirlpool I IYes INo
Basement: DYes ❑No Basement Plumbing: IYes :]No
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business Total Square Footage of Building #People
#Sinks #Commodes #Showers #Urinals
Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) I
FOODSERVICE ONLY: #Seats
Type system requested:conventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type:C County/City Water ❑New Well ❑Existing Well D Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve?C Yes ❑No
If yes,what type?
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that
any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if
the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative
of the Davie CountyPHehepartment toconduct necessary inspections to determine compliance with applicable laws and rules.
I unde land that I aible for the proper identification and labeling of properly lines and comers and locating and flagging
or s g the housecation,proposed well location and the location of any other amenities.
Pr a er's of owner's legal representative signature Site Revisit Charge
_ Date(s):
2-- 2, / Client Notification Date:
Date EHS:
Sign given I Yes❑No Account# iq_q 0
Revised 11/06 Invoice#
` DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760 Fax#(336)751-8786
OPERATION PERMIT
Account #: 989900025 Tax PIN/EH #: 5789-85-0766
Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#22
Reference Name: Location/Address: 148 Maplevalley Road-27006 .
Proposed Facility: Residence Property Size: 131x230
ATC Number: 4773
**NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC 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.
Qy —
SystemType:%( S.T.Manufacturer Sb ws F Tank Date lo-Lir Tank Size
Pump Tank Sizeji
System Installed By:Let Nlc4 ' P4- E.H.Specialist:_%j Date:
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DCHD 11/06(Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH J
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760 Fax#(336)751-8786
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 989900025 Tax PIN/EH #: 5789-85-0766
Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#22
Reference Name: Location/Address: 148 Maplevalley Road-27006
Proposed Facility: Residence Property Size: 131x230
ATC Number: 4773
Site Type: ew ❑Repair ❑Expansion
**NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A
Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF,FIVE YEARS. This ATC is subject to revocation if site plans,plat
or the intended use change.
Residential Specifications: #Bedrooms 3 #Bathrooms 3 #People Basement❑ Basement plumbing❑
Non=Residential Specifications: Facility Type #People #Seats
qq Square Footage(or,Dimensions of Facility)
Lot Size �'�94� ��' Type of Water Supply: RonCounty/City ❑Well ❑CommunityWell
L
System Specifications: Design Wastewater Flow(GPD)3 (RD Tank Size I 16 00 GAL.Pump Tank i� AL.
Trench Width Max.Trench Depth 3 Rock Depth Linear Ft.
As stated in 15A NCAC 18A.1969(5)
Site Modifications/Conditions/Other: accepted �tamc m2 y also be ut;--
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30-9:30am.on the day of installation. Telephone#(336)751-8760.
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Environmental Health Specialist Date: (� —673
DCHD 11/06(Revised)
`k.
Dick Anderson 336 998 7279 p. 1
nem � . ... �..� ...._. -._i._.. _.._..----•- -
f
Q I EVALUATION/IM PROVEMENT PERMIT&ATG
D County EaYironmentat IIealtla
Boz 8481210 Hospital Street
�+ Mocltsvilie,NC 27018
Q1r� 2� (3 )751-8760/Fax(336)751-8786
A Foe: nvenitat e®ii UAuthorizationTo Coaun=(A-LC) O Both
T W cm Mepai xisting System DExpansion/Modification or£xisting System or Facility
t� `Y1>'' ettl'1t
'••IMPORT APPLICf.TTONCdMVOTBEPROCFSSEQLNLESSALLGETHEREQUIN D
ION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION �t�► ( i
Name to be Billcd f &�o-� &A &�S'r•ConEact Person_ b'�� �J"4v,—
Billing Address 2 LS_k2:u. Home Phone r s 7! 914-1
Citr/$tatdLlP Bstzs - e^ z?o?-S B=nhess Pltonc- d g ?Ts75 --
Name on Permit/ATC if Different than Above
Mailing Address- CityiStateop
PROPERTY INFORMATION *Date House/Facili Corners[lagged
NOTE: A survey plat or site plan nut accompany this application. Included:O Site Plan UPlat(to scale)
(Permit isva�"t for 60 mouths with site plan,no expiation with cotrplete plat) A
Ownces.Narrh.e. 4.7r1p-v-- ti d&4,#.- - Phonr-N aZ91,
Owner's AddressZ6 4S 101 l J CMor{%ity/State, .
Property Address�� iyt l�L C'i to 1+4 at%-a-
Lot Size (3 I Y. Z 3n Tax Pn1W
Subdivision Natrte(if applicable) LK A ectienJLotp--j_�
Directions To Site:
If the answer to any of the following.Iu,-stions is"yes",supporting document htion must be attached.
Arctherea l y.99.-
Docs the silt contain jurisdictional wetlands? GYe:ENO
Are there any rasenaarts orrighloof-ways on the site? UYes b'.ItS
Is the site subject toappromdl:yanaherpublic ageacy? flycrfNG
Will wastewater tithei than dmvstic sewage be generated? CYc:g?ir
IF RESIDENCE FILL OUT TH13 BOX BELOW _
#People _�� #Bedroam� /!Bathrooms Garden Tub iripool Oyes EMKO
IBSsr—,=t:OYtx Fk o Basement Plumbing; UYes GAZA
IF NON-RESIDENCE FILL OL T THE BOX BELOW
Type of Facililyffiasur_Pss _ Total Square Faota;;e ofRuilding_ #People
#Sinks #Commodes_ #Showers #Urinals
Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICEONLY:#Seats
Type system.,lucste��d��:.��G nventiwut CAccepted Olmovative OAhertative OOiher
ta
Water Supply Type: ,teauatylaty Wass rJ New Well OEais.,ng Well 01 Community Well
Do you anticipate addi,us or cxpansiof a addle-facility this systemis i"r..-IM to wave?11 Yes. aim
If yes,what We _
This is to certify that the informttion prcvided on this application is true and tarrect to the best of toy knowledge. I understand that
any permit(s)orATC(s)issuedlxrean-aresu*atnmmpcwi^nocrevoeui3 if dwsitcisalteredtheintended usechaogcs,ofif
the information submitted in this application is falsified or changed. I bcrcby grant tight of entry so the Authorized Representative
of the Davie County Health Departmera to conduct necessary inspections to d:termine complismee with applicable laws and rules.
1 underspadjIM11 am responsible for tlhe proper identification and labcft of property lines and cornus and locating and flagging
ors n housdf ity I 'on.proposed well location and the location-N wry otter amerities.
Site Revisit Charge
roperty owner,or owners legal repme entative signature
Daic(s):
ID 0Client Notification Date-
bate
ateDate Elis:_ �(a
Sign given Oyes Onto Aceouaf# t+ 1 o O O��
Rcvtstd 11/06 Invoice8
Dick Anderson 336nn9/987279 n/ p. 2
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• APPLICA llaV FOR SITE EVAW4TtON/11MFROVEUDa PE)tNIT R ATC
Davie County Health Department
'.Envlianmental Xaa/th Sechba '
P.O. Box B48/210 Hospital street
Mockeg4114. NC 27938
(336)751-8760
•••ZMDORTANS••• T=S "PLICATIONCAMWr BE PXOCSSSED MV=S ALL TRS RSQ=RXD ,
THFORMATION IS YROVTnrn- Refer to the XNTORtATION BOLLETIN for inatructionn.
✓1. x.e. so a•Btll.a /GC�it/IIE�•'pl)��flS�-L.v1G`eeoe.ec r.r.an �sSIUL�iV��K.Sd�
✓A..liaeq Jlddress _�G(�/N(,-ETT✓G��t/ �N Hfwro!bone y 7�"7�J�9
(„-2. U-11ty/3t.te/z12 /YIAI'�F'St/ILt+4L a(-
,,-2.
bee.on Petvic/ATC I-Lgitttront trim Above
M.111ai mAdrua city/it.p/rrD
,—i. application For: Ksits IAaluntioa O uprovament Permit/ATC 0 Both
,rt. eye%—to Bedytee.XIInuae O mobile IIomo 0 nueineea Ct Industry O other -
,•,ri. Type er•tc•.r.wo.tood. 0 Co�.ntloo.l 0 coa•ostioeal sQdLfted 0 re.oy.ttye
--s. If koosideaees I People I Bedrooms e Sathroome
--r' idDi,iw.h.r L70.r7reBe Dloaew.l &•kip)reo►fa. DiwewValuebreg On"oeo.s/No aluebieq
T. it eueinea./Industry/other: "city type a People I Stake
I Cmmedee a 1:2 y ra I Orrnale a water coolers
IF FOODSERVICE: M Soatta Natimatwd wetgr vesgg (gallont P!S 4ey1 -
--I. Typo of water supply, (YCoua:y/City 13 well Ll Conxw=ity
S. Do ycu antictpete addrtioda oc expansions orthe racrlity this system is intended to serve?0 Yes 0-'NQ
r
lfya,trhatt ____
1MPORTAM-”CLIENt i dIUSTfO PGL'!8 THt:REQUIRED PROPERTY INiORMATION REQUESTED
DE. EltkcraPLATerSITCAI ryTBESr/dN177ED0 tReellmt e115THISAPPLTCATHRI.
Lf7rroperty Dimensioar. a�A, . S�i RITE D1Ri,CTIONS T£rom Modumtre)to PROPERTY:
I Gas cae-�
�t'ax office rev: p ?8 7 6 3�� •ys lSB tZi ffv S • Tv
—PtopertyAgdrep: RaxdNuz:e_fl -*SjGYf�L/�
Citymp��ll�,t)C - A 6.Z70?X
f Ipa Subdlvirlan rovide InroreuKin,as follows:
Ksme. /14,41MO W004 C 1It7S+6 4
Section: Block. baa &+!late home comers flagged: jl Qa C" �'/-At n
This is to certify that the tnfortuatloa provided is correct to the best of my knowledge.I understand that say peralit(s)
issued hereafter are subject to suspension or revocattaN It the ilia plans or intended use change,or if the inrornutton
snhmltted In this appliotloa is ratsiftd or Clrangt�l 1,nlsp.rmdrrnandther[n+q nesponsrblsfaralf4sarres inearred from
misapplication, 1,hereby,give consent to the Authorized Representative or the Davie County Health Dcparhntnt
to enter upon above described propert.•located in Davie County and owned by
aa - G
to conduct all testing procedures as mccary to determine the rite sni . i
i
L--DATE ?-eR.7� -O S •-9CKATURE
THIS AREA MAYBE!)SED FOR DftAWENG YOUR SITE PLAN(Include a0 or the following: Existing and proposed
property lines and dlnwasiorrs,structures,setbacks; and septic locations).
Site Revisit Charge
Datc(s).
Client Notification Date:
EBS:
Sign givenAccount No.
Revised DCHD(05!03 Invoice No.
- DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICA�1-'FrM4ItMUM 85 Tax PIN/EH#: p$fj 4,IMORMATION
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 Date Evaluated:
.
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6" 7
Landscape position L•.
Slope% l
HORIZON I DEPTHG`-
Texture groupC SL
Consistence r (j,
Structure A Oto.."
Mineralo D
HORIZON II DEPTH )�—
Texture group Is C
Consistence
Structure s kv
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
MineralogX
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: �t-�-��` � EVALUATION BY: 1n m ac±t�'1a
LONG-TERM ACCEPTANCE RATE: G ' 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
r e
'SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Pristpatic
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
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOQ
Soil/Site Evaluation
APPLICANT'S NAME DATE EVALUATEDO
PROPOSED FACILITY PROPERTY SIZE a �d
SUBDIVISION I// tYX(4140 ROAD NAME
Water Supply: On-Site Well Community Public 1/
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position L
Slope% �J
HORIZON I DEPTH 6
Texture groupG C!�
Consistence i
Structure
Mineralogy 1,J4- 1
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
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: 7 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
Mineralog
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(01-90)