149 Primrose Rd Lot 4 ` DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760 Fax#(336)751-8786
OPERATION PERMIT - l4 C 1 V1;4IZcTl-
Account #: 990002285 Tax PIN/EH#: 5789-86-6318
Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#4
Reference Name: Location/Address: Primrose Road-27006
Proposed Facility: Residence Property Size: 1.82 ac.
ATC Number: 4650
**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.
System Type:J S.T.Manufacturer Sh oaC Tank Date-5-2t-67 Tank Size 1000
Pump Tank Size__/4 A- 760 IT
System Installed By: La Yeti "V—%%vt E.H.Specialist: ADate: g'17-01
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DCHD 11/06(Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street / l
Mocksville,NC 27028
(336)751-8760 Fax#(336)751-8786
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990002285 Tax PIN/EH#: 5789-86-6318
Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#4
Reference Name: Location/Address: Primrose Road-27006
Proposed Facility: Residence Property Size: 1.82 ac.
ATC Number: 4650
Site Type: ❑New ❑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 #Bathrooms #People BasementRlasement plumbing&`
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size / Gzt+.� Type of Water Supply: aunty/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow(GPD)11? Tank Size l'do d GAL.Pump Tank/�/AGAL.
qfTrench Width 3G `� Max.Trench Depth 3G 'Rock Depth 2� Linear Ft. ?`
5�(l
Site Modifications/Conditions/Other: As stated in 15A NCAC 18A.1969(
aceepted Systems mai' also bn 11SP0
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30—9:30a.m.on the day of installation. Telephone#(336)751-8760.
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Environmental Health Specialist Date:
DCHD 11/06(Revised)
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APPLICA 11ON FOR SITE EYALVAT(ONItNIFROVEUNT PEiLNIT&ATC
Davie County Health Dopa Mgnt
En vilvnmenta%Haaltlr section
P.O. Box a43/210 Hospital street
Hgg4oTill4. NC 27938
(336)751-8760
♦wwZ2(p=AVTwww THIS APFLICATSO.Y CAtI WZ BE PROCESSED MU=S RLL TR8 RZ=RSD
17JlOti?tA7ZOlr ZS YRAv1II8a../t Refer to the ZZ•7F0&101TI0N 3171LST1Nfor Instructiona
✓f. nu. ss be alll.i / �/`7I�/�J /)��57'1,✓L`G,�„qc«c t'.r.on �L?iV,C /C.-8dA)
e�Ttaisi.g Aedrese��t:(Jii/G-E•/.a✓�tl G.1! V,ra..fT.aoa. �/7�t-'7 S"/9
4/c1ty/statolzzr M6C4-s✓/Ct.E .('. .270.29 ggS-7.P,7'?
y Z. N.ra o. ftc"C/A=it o .art than Above
Nailinq addrw City/state/L1pI� ?•i)/
,—I. Application For: Ksit. rvaluatioa Cf*x.PrGvement par7di.t/ATC D Both
,�-4. errs—to s.e.l.a.Xttouae 0 uobila Boma ❑ Business d Eaduatry 0 other
mss. lyy.armee requested. O con-entzooal ® cod.estlosal aoditied imwaeiw
--s. If Xeesidence. 1 Foople / Bedromw _ 0 Bathrooms
1 �IDlalwaMc 1.7a.r3ag.nlanewai .ekiza luelaLe yl—blw9
7. It au.lo.se/Ioduatry/Mier, verify tn. t Frople a Slake
a Cm od.a a t]o.era t nriesia a Nater Coolers
Ir MDSZXVZLEt 9 Sogtte X9ti--qt:9d water gang* (yauoca Per dry)
--I. 7ype of sat" supply. C1'Coun:y/City D well Cl Coamuaity
F. m you antielpate aaditi*ns or Mansions orthe facility this system Is intended to scrvc7 C3 Yes OT40.
LsltORTiWI`ww CLII Nth MUSTeO t'tZTETHE REQUIRED PROPERTY ItVEOttMATION REQUESTED
6 FJthtraPLATerSITGPL pryTBESf/BHf77EDb tbeel[eot a+1AtTHiSAPPLICATION.
L---i<►operlyDimensions:_ � • S Pi ggCeZ5 -WRITEDIAEC'rtous(fromM*duvllk)toPROPERTY:
o•TaxOffice I'M a W9 YZ63'AV O N 158 ro flvl S yD oCASS o/ v l c
�.�ropcctyadgt * RoadNarae tyP�s1G2Ef��ly I� oZA6.
Cllyrzip�)JQy C,E J C 4270.ar
f In a Subdtvidbc iovtde tarorwtian, r.
;as follow
Kayne: Im /L
'4CF1 192624 f TH/l5,6 4A
Section: Black: Lor._ �_ &4rate home corners tlar:W. / 't4c'
TLis is to certify that the lnforltlatloa provided Is correct to the best of my knowledge.I understand Ulat any permit(s)
issued hereafter are subject to suspension or revm2don,It the site pians or intended use chaW,or it(he inrormation
Submitted In this appltotlon is fatsifled or cbaacni 1.friar. Incarred fro n
this application. I,hereby,give consent to the Authorized Representative of the Davie County FReAth Dcpartmtnt
to enter*poll above described propest•located in Davie County and owned by
to conduct all testing procedures as ncc.yaarr to determine the site Sul
n i
L--DATE ..! 'a. -O S '-SIGNATURE 1�
TH15 AREA MAY BE USED FOl'L Dn,kWrNG YOUR SITE PLAN(Include all of the following: ExistLn and proposed
property lines end dhmeuslons,structnR3,setbacks, and septic locations).
site Revisit Ckarfc
Datc(s):
Client Noti(icatioa Date:
ENS: ry
Sign givenAccount No. Po J
Revised DM.D(il-W Invoice No. -
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
ccoun . 990002285 Tax PIN/.EH#: 5789-97-0344.64
Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Phase 4 Lot#04
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
Slope%
HORIZON I DEPTH O -1
Texture groupC
Consistence
Structure
Mineralo
HORIZON I1 DEPTH 1 2
Texture groupk
Consistence r
Structure
MineralogyS.
HORIZON III DEPTH Z 5
Texture groupt_ 10 LS
Consistence 0S ho
Structure C�
Mineralogy5
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION S
LONG-TERM ACCEPTANCE RATE O. O• `
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: •3, OTHER(S)PRESENT:
REMARKS:
LEGEND
andscape 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
Tyxture
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
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-Prisrpatic
Mineral=
1:1,2:1,Mixed
Notes
Horizon depth-In inches
Depth of fill-In inches
Restrictive horizon-Thickness and inches from',,and surface
Saprolite-S(suitable),U(unsuitable) I'
Soil wetness-Inches from land surface to free w4er or inches from land surface to soil colors with chroma 2 or less
Classification-S(suitable),PS(provisionally suits le),U(unsuitable)
LTAR-Long-term acceptance rate-gal/day/ft2 � - .
2.oa. 5 t
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MAR 112011
Davie County Health Department [AVlECOUNIYHEALit,0�r"►���''
vironmental Health Section } '
k
� � P.O. Box 848 �
t r. 21.0 Hospital Street T ��s
' c?U A� '�U t 09-40-06
Courier# :
�, ` ' M J Mocksville, NC 27028 a'
Plione:(336)-753-670; Far(336) -753-1680
ON-SITE WASTEWATER CERTIFICATION FQR DWELLING
(Check One) Replacement Remodeling /Reconnection
Name:, 6;_/ef Phone Number 93� ff46 30 S`r (Home)
Mailing Address: f�f�: 2/h-!/`Gs IC 2c/ c?j3 G �J7 ��/C► (Work)
�c/yti SCC
Detailed Directions To Site: /J
I �./Ps �7acrc�j �vds �C�ccld/a ��cp /G,E
�f D/I /��` D/a//li/jc1� ��� %moi/e`` 'iti��f L��f S.�rJoc/r '"k, lei;
Property Addrdss'� Peel,-7/r S tf
Please Fill In The Foljowing Information About The EWSTIIVG Facility:
Name System_Installed•Under: t G Ce/ )?K6641 eX Type Of Facility: A 7C - eCS/c-le4C e
Date System Installed.(Month/Date/Year): �! �?/ ZaG� Number Of Bedrooms: `T Number,Of People: 2—
Is The Facility Currently Vacant? Yes If Yes,For How Long?
Any Known Problems? Yes If Yes,Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: ISIde- SfWG •e Number Of Bedrooms: Number of People
.Pool Size: Garage Size: /7//4 Other: 12�1.e/1<'e' S/ 0
Requested By: Date Requested: 916100111
gnature)
For Environmental Health Office Use Only
Approved Disapproved
omments:
Environmental Health Specialist Date:
*The signing of this form by the Environmental Health 9taff is in no way intended,nor shouldbe taken as a guarantee
(extended or limited)that the on-site wastewater system will function properly for any given period of time.
Payment: Casl Check Money Order # Amount:$ D.DD Date:
Paid ByReceived By: -
Account#t: ���7i Invoice#: �Z