159 Maple Valley Rd Lot 19 DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
OPERATION PERMIT
Account #: 989900025 Tax Purl/EH#: 5789-85-0550
Billed To. Dick Anderson Construction Subdivision Info: Marchwoods Lot# 19
Reference Name: Location/Address: 159 Maple Valley Road'-27006.
Proposed Facility: Residential Property Size: 0.707 Ac.
ATO Number: 5120 /6q V,111Zq
**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 WAIT be taken as a guarantee that the system will function satisfactorily for any given period of
time.
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System Type: - S.T.Manufacturer j� C' Tank Date ` Tank Size r/ QOC�
Pump Tank Size / /Q
System Installed By: E.H.Specialist:4(ZM;�46e: -.! r/
GPS Coordinate:
2P d6v
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DCHD 11/06(Revised)
• DAVIE COUNTY ENVIRONMENTAL HEALTH
' 4
P.O.Box 848/210 Hospital Street
' Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account M 989900025 Tax PINfEH#. 5789-85-0550
Billed To: Dick Anderson Construction Subdivision Info.,-. Marchwoods Lot# 19
Reference Name: LocationiAddress: 159 Maple Valley Road'-27006
Proposed Facility: Residential Pcoperty•Size: 00.707 Ac.
ATC Number: 5120 Site Type: Er 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.
u �
Residential Specifications: #Bedrooms ` #Bathrooms 3'5#People Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats r
Square Footage(or Dimensions of Facility)
Lot Sized •-70 Type of Water Supply: County/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow(GPD).Z/40d Tank Size It to GAL.Pump Tank GAL.
Trench Width G Max.Trench Depth L Rock Depth Linear Ft.
As stated in 15A NCAC 18A.1969(51
Site Modifications/Conditions/ they: �rrnpted—�uat�rz�rrs ,Ise-},� 7�,.r
Contact the Davie Countonvironmental Health Section for final in ection of this system between
8:30-9:30a.k pn the day of installation. Tele ho # 336)751-8760.
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Environmental Health Specialist Date:
DCHD 11/06(Revised)
Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028 �k
(336)753-6780/Fax(336)753-1680 ��
IMPROVEMENT PERMIT
Account #: 989900025 Tax PIN,EH#: 5789-85-0550
Billed To: Dick Anderson Construction Subdivision Info: : Marchwoods Lot#19
Reference Name: Location/Address: 159 Maple Valley Road'-27006
Proposed Facility: Residential Property;Size: 0.707 Ac.
ATC Number: 5120
**NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An
Authorization To Construct a wastewater system must be obtained from this office prior to the
construction/installation of a wastewater system or the issuance of a building permit(in compliance with
Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permitis subject to
revocation if site plans;plat or the intended use change.
Permit Type: 0New ❑Repair ❑ExpansionPermit Validdffor: E13 Years ❑No Expiration
Residential Specifications: #Bedrooms—q�l #Bathrooms 3 it People Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): Type of Water Supply: 'County/City ❑Well ❑Community Well
As stated in 15A NCAC 18;1.1969(5)
Site Modifications/Permit Conditions: accepted Systems rnay also h�_ usecd'
System Type LTAR
Initial c .t. O
Repair o 1 c .7-7
Site Plan 1
taa
lgy
So
Environmental Health Specialist Date
i.p.11-06
1
APPLI FOR SITE EVALUATIONAWROVEMENT PERMIT&ATC
Davie County Environmental Health
P.O.Box 9=10 Hospitd Street
Mocks;Alle.NC 27=
(336)753•6780/Fax(336)753-1680
�!pplic>Et�on Ear 'onllmprovemeett Permit �u@wrintim To ConstrucKATC) +gosh
FTI�tT pe pf A ii;;tie t ew System (.'Repair to Existing System LtExpsnsionModificaion of Existing System or Facility
600WORTANI0'THIS APPLICATION CANNOTREPROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Referto the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION �A
Name to be Billed d eons LXcootact Person i��,44YcL r Sou
Bolling Addresa JJ• C 14e— Home Phone •
City/5tmdZIP to IJ '!.– L7 Business Phone
Name on PcmtWATC ifDiiftrent than Above
Mailing Address City/StatelZ
PROPERTY INFORMATION ;Date HatwRacility Corners FI ed
NOM- A survey plea or site pion must wwmpany this application. Included:0 Site Plan OPlat(to scale)
(Permit is►slid for 60 months with site plan,no expiration with complete plat) "9'12-7?
Owner's Name.b_i_t!IL Aad 4'�.,d ru Phone Number�3�fi
Owner's Address 2.Z5 :wLw as L gty/S t ip t7i O- 7,7 1 AB
Property Address g. City 41 O.L.. 2'.100,4.
Lot Sirs 010 Tax PIN# 57 -R, -0 O /9 ��2 Nei- axdf/Stl� ��"/Z:-/o
ioa ( -
SubdivisNamo(if is le) M O sextiew/Lotu
Directions To Site
Ifthe answer to dry of the following Questions is`yes".supporting documetuation must be attached.
Are there any existing wastewater systems on the site? C Yes am
Does the site contain jurisdictional wexluds? UYes Iwo
Are there any easements or right-of-ways on the site? L'Yrs tt m
Is the site subject to approval by another public agency? C Yes Iwo
Will wastewater oder than domestic wwage be generated? I Yes titin
'IF RESIDENCE FILL OUT THE BOX BELOW
0 People #Bedrooms d Bathrooms 3,95 GardenTublWhiripool[:Yes 14340
Basement--.]Yes tW6 Basement Plumbing: 9Yes &No
IF NON-RESIDENCE FII.L OUT THE BOX BELOW
Type of Facility/Busiaess Total Square:Footage of Building #People
#Sinks *Commodes #Showes #Urinals
Estiauted Water Usaae(gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: #Seats
Typasysu-rcqucstdd: alConvemiocat I]Aeupled ninnovative OAlternative OOthcr
Water supply Type:'�otmtyiCity Water O New Welt C Existing Well n community Well
Do you anticipate additions or expansions of the facility,this system is intended to sone?J Yes +ytdo
lfym what type?
This is to certify that the infemmtien provided on this application is true and correct to the best of my imowledge. I trderstard
that any pervtiKs)or ATC(s)issued hereafter are subject to suspension or nevocatioa if the site is altered,the intended use
changm or ifthe information subnined in this application is falsified or changed I hereby gran right of entry to the Authorized
Representative of the Davie County HUM Department to conduct necessary inspections to determine compliance with applicable
laws and rules. I understand that l am responsible for the proper identification and labeling of property lines and comers and
toe i 1 alcing lbe bouse/faeility location.proposed well location and the location ofany o&a smetuitics.
Property owner s mowser's legal reI Psi ntati siguni ueaiure Site Revisit Charge
Dak(s)-
O
- oro Client Notification Date:
Date EHS:
Srgn given I1 Yes ONo Account i d 0 N26'
Revised 11/06 Invoice It
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http://maps.co.davie.nc.us/GoMaps/map/mapframe.cfm?CFID=4129&CFTOKEN=61640... 11/12/2010
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 989900025 Tax PIN/EH#: 5789-85-0550
Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot# 19
Reference Name: Location/Address: 159 Maple Valley Road'-27006
Proposed Facility: Residential Property Size: 0.707 Ac. Date Evaluated:
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape p2sition
Slope %
HORIZON I DEPTH
Texture groupG
Consistence L5 Ar
Structure
Mineralogy
HORIZON H 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 nl
SITE CLASSIFICA ?
TION: /" EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: t�• a ? 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
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
�-_zssification-S(suitable),PS(provisionally suitable),U(unsuitable)
\'R -T nnv-term arrentnnr•P rate-oal/rha/ft7
■■■■■■■■■■■l■■■■■■■■■■■■■■■■■■■■■■t■■■■tree■■■■■■el■■■■■■■■■■■■■■■
■■■■l■■e■■/i■ee■t■e■■e■te■eet��e■■e■to■tt■■■e■■■t■■ttttt■et■■ee■ttt■
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■■■lrnt■e■t■■■e■■eltelle■le■■■■l■ ■■■■■lt■■te■■■e■■■tl■■l■■telle■■
■I�IG�i■■■■■■■■■■■■■■elle■■■■■■■■■■■tlt■■■■■■■■■■t■■ell■■■■■■■■■■■■
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■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■/■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■/■
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voviw 4.2 tea ui ; T+7(' uit:h f1f141Cf 5Vf1
` APPUCAI lONI f0$SITE EYAItfATIOVMPROVE1tM PERMIT d ATC
Davi*County Health Department
Env/ronmental Health Section
P.o. sox Baa/zla Hospital street
Mock.jvi31s. hQ 2793*
' (336)751-8760
•••MIMSTAHr—, 24125 APPLZCATIDN CJLNf 7 BE PROCSSSED SSS ALL 7M V=1VIRIM
INB MKTI01r IS YROYXn=. Refer to the XNMMP=ON BVI MXN for iuetsuctiona.
.-
✓i. V.se to be villadA)
/GC.I�i�t1//zCs��/cad`D�IJSF-lit/C.(�,�,t•cc r.r.un L7�4lClG�iN�r C-B
e/Iteiitey AAdr•se GV/q/G-H4y,! l/ 4AI Vlfw•then. 7� 75''7
✓city/dc.celZa NJA��SL/lL�E i{l(' ;170340 c—aa.L .,.Phone CtQifl-7a.7q
t�—r. Me—— P--Lc/A=3t o er•et tam ADay.
M.ilt.g addr—. ctcy/scua/sip
Application Yor. KSita Ivaluation ❑X=Provtmet}t Dermit/A.TC O both
--{. &rete.to&e.-la•. rd 1louse ❑ Mobile Mcno ❑ Sunine.. CI xnduatry 13 other
,eerie Trp.•y.t—reduuteedl. ❑ co ontsoaal (9 non-e.Uow x-odirted E) Sano-atia•
.:tea. If kkoosidence. ✓f People I Bedrocow —3— h
— a Batroo=
-r R-Ol,lw.Ler 01—ba&•Dlayehal a.liuy keaAL• ❑8uer.Vrlu btsg ❑auw.tht►plueblwg
4. It Dusloea./Iodustry/Other: verify type A People a Stnko -
a CoAendu a 1]o-are f urinals a Vater Ceolera
It MDSMVXCN. # Saaa/t& =&tuna-- w4tsr, IIPage (yauooa Pr d.y)
-tea. Typo of.racer.apply. tL COun:y/Cit r ❑ wall ❑ Catvouai ty
s. m you aatictpat*additions or expansions orthe fatuity,this system is intnrded to serve?❑Yes 011f0
Ifyts,svhatt . ____
LNP01t7R17—CLIvyriMUSTCO PGLMTHEREQUIREDPROPERTY114FORMATIONREQUESTED
6 VOrcraPLATorSITEEL ryroz=Ih f7TEDb tbeelleat xitbTHIS APPLICATION.
roperty Dimensions.�3 . S Si �pJF_C;- TRITE DIRECTIONS(from Mocksvltk)to PROPERTY: .
—Tax office PIN: P 79 9 Y 7 G 3 S 158 M &JI s • yz) P156yeE-S Cl leF
—,Prapertyaaeressp RnadNarm I��JPe-&s�1CII�
Citymp��LC,E /1/.0 j270,,-X
f in a Subdivide- roAdc informatim,as follows.
Name: 1".46K"1VW24 a R14SE- el- moo,.
Seaton: Block: Lor. "� cDate hamc eemers RaerW: �?.4Gt�7� ,e2 v�� /76c-cl
This is to certify tbat the information provided Is correct to the best of my knowkdge.I understand that lay perinit(s)
issued hereafter are subject to suspension or rtvoeatfoq If the site plans or intended use change,or it the infornution
submitted in this application is fahifird or ehangcd.I.alae,imlrrsrpndrhef[afq rerponsillsjor atf tharges inearred from
this applicaden. I,hereby,give cement to the Authorized Reprtscncatfve of the Davie County Health Dcpariment
to enter upon above described propert:•located in Davie County and owned by
to conduct all testing procedures as accessary to determine the site snt
r✓DwTE ..1-A.1- O s --SICdATOttE
CT
THIS AREA MAY IIS V=FOR DRAWING YOUR SITE PLAN(Indode all of the following: Existint and proposed
property lines and dimension;structu:ts,setbacks, and septic locations).
Site Revisit Charge
Dak(s)•
Client Notification Date:
EHS:
Sign given 6 Account No.
R"ked DCHD(95M3 Invoice No.
DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
5 Tax PIN/EH#: 5789-97-0344.22
t.' r Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Phase 4 Lot#22
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
Texture group
Consistence
Structure
Mineralogy
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: 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
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-Prisipatic
Mineral=
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 LOT
Soil/Site Evaluation
APPLICANT'S NAMEDATE EVALUATED
PROPOSED FACILITY PROPERTY SIZE Z �G
SUBDIVISION � ROAD NAME
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit f Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope% o
HORIZON I DEPTH
Texture group '
Consistence
Structure 1
Mineralogy C147
HORIZON II DEPTH y ��
Texture group
Consistence i
Structure /G
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
/� r
SITE CLASSIFICATION: 62 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(01-90)