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171 South March Ferry Lot 29 1 DAVIE COUNTY HEALTH DEPARTMENT p Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT /.7/ J f'lm ah -fat Account #: 989900025 Tax PIN/EH#: 5789-76-5851.29 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#29 Reference Name: Dick Anderson Location/Address: Peoples Creek Road 27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number: 3048 **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. Residential Specification: Building Type #People #Bedrooms #Baths Dishwasher: Garbage Disposal: ❑ Washing Machine;0 Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Water Supply Design Wastewater Flow(GPD) c�7> Site: New Repair❑ System Specifications: Tank Size,/00 GAL. Pump Tank GAL. Trench Width�'6 Rock Depth 2`� Linear Ft� Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) 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 da of in tallation. Telephone#is(336)751-8760.**** Environmental Health Specialists Signature: 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 M 5789-76-5851.29 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#29 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Pro osed Facility: Residence Property ATC Number. 3048 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 WASTEWA CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �- �L( Date: 1-2�` (�2 iS 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 thai the system will function satisfactorily for any given period of time. % ,I �t 1 � SToJ� 1 146 0 rv-04► Septic System Installed By: i'1 Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) APPUCATION FOR SITE EVAUJATION/IMPROVEMENT PERMIT&ATC r • . _ , Davie County Health Department D v• ' finv/ronmental Hes/0 Section • P.O. Box 869/210 Hospital Street ()i-C 71999 Mocksville, NC 27028 (336)751-8760 IL ***I1PORTAN2*** THIS APPLICATION CA10M BE V20=83M UNLESS WZ THE REQUIRED 11M MIITION IS PROVIDED. Refer too' the IMIUMAT=OSI BULLETIN for instructions. 1. 11w to be allied Z?e1y 4"i2e�$ �l a A I#1 S r Contact Peceack Wailing Address c;A:5 A S LAID )G.A)A " LA/ , aosamePhone 4��qA— 7 5 7 9 City/state/aIP 410"C V/t.t.�• Al.NC. Q 7o Ir susiness Phone 97F'- 7A7� s. Mase on Perait/ATC it Dilferent.than above Whiling Address City/state/sip a. Application ror: Site =valuation. 0 Improvement Permit/ATC O Both s. system to service: House O Mobile Home 0 Business (] Industry 11 Other s. If Residence: f People E Bedrooms rYl_ OSf Bathrooms Dishwasher Xoarbage Disposal `mashing Machine O sassaan�t/Plluuabing U SasseentMo Plumbing 6. 2t Dusiness/2ndustsy/Other: "city ,type # People f sinks # cossodas / showers Urinals # Water Coolers It I=SERVICZ: # Seats Estimated Water Usage tgallons per day) 7. Type of water supply: 'county/City 0 Well 11 community e. Do you anticipate additions or expansions of the hellity this system Is Intended to serve? 0 Yes �No If yes,what type? ***IMPORTANT***CLIENTS M FCOMPLETETHE REQV7RED PROPERTY INFORMATION REQUESTED BEIAW. Either a PLAT or SITE PLAN MUlST BESVBI fnM by the client with THIS APPUCATION. Property Dimensions: AA0XQ K AI-A.;k Ae / f WRITE DIRECTIONS(from MocWlle)to PROPERTY: Tax 081cePIN: # v�7 S9 76"s��I1 29/ � '70 Ta ESO1L�.� Property Address: Road Name ,Wi6E/C - LEFT (/�1 /'Y)1 LA 7-D City/Zip MA&4 w uM 3 H in a Subdivision provide Information,as follows: 4140 G g Name: MA2G14 L)060s Section: Block: Lot: Date Property Flagged: This is to certify that the Information provided Is correct to the best of my knowledge. I understand that any permit(s) Issued hereafter are subject to suspension or revocation,If the die pians or Intended use change,or if the Information submitted in thb application is bbiRed or changed 1,also,understand that Ian responsible for all charges Incurred from 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 nitsbultv. DATE I� 1 " cT 9 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 Date(s): Client Notification Date: EHS: Account No. d°2 Revised DCHD(07/99) Invoice No. 1 �` -� r. r W y f 6 t 14- ad AI .=- N Az N l43 l 4 4 =� 04 / N 4.-7 110' �►" 1 (zo, 491QC11 i I1q A)�/) IL `po U 1 CW v - X I NCl- 09k a • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SoiVSite Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900025 Tax PIN/EH#: 5789-76-5851.29 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#29 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre Date Evaluated: Water Supply: On-Site Well Community/ Public (/ Evaluation By: Auger Boring Pit t/ Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope% HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 3 ' Texture group Consistence / Structure Sit b/i Mineralogy /.'t A- 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: G7) EVALUATION BY: LONG-TERM ACCEPTANCE RATE: t( 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)