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180 March Ferry Rd Lot 45 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900025 Tax PIN/EH#: 5789-76-5851.45 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#45 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number: 3211 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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 Machine4d'�Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial13 Waste: Lot Size Type Water Supply Design Wastewater Flow(GPD) Site: NevemriRepair❑ System Specifications: Tank Size/QD� GAL. Pump Tank GAL. Trench Width-7 Rock Depth 1��Linear F a�/ Other: Required Site Modifications/Conditions: IMPROVEi11ENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative 2LIbe Davie County Health Department for final inspection of this system between 8:30 a.m.to 9:30 a.m.or1:0 : 0 p.m.on the day o tion. Telephone#is(336)751-8760.**** Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 989900025 Tax PIN/EH#: 5789-76-5851.45 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#45 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number: 3211 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 WASTE WA C NUCTION IS VA FORA PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: / 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. �U DX X� y h Septic System Installed By: Environmental Health Specialist's Signature: Date: A/o DCHD 05/99(Revised) APPLICATION FOR SiTE EVAUlAT1ON/1111PROVEMEM'PERMIT do ATC r �, Davie County Health Department OWIE Environments/Mea/th Se+ctlon P.O. Box 849/210 Hoapital street DEC 71999 Mockaville, NC 27028 ` (336)751-9760 ***ZMPt7RT1lN?*** THIS "PLICATION CAM= BZ PROMUD UNL388 TILL %= A3QUIR3D INPORMIITION 18 PROVID3D. Refer to the INrORMATI= BU=TIN for instructions. 1. Naso to be aillod ArAk 74Ne�F_nbdal•G,ivS7- Contact persontlIC&ANG&,A'-Z0A) Hailing address a A S LAI fA)G 14Ayg: ) LAI , am& phone WA- 7 57 9 city/state/sip J�LIDCIGSV/c,t..0 f AZ C. oR 70AX, Business phone 9qk- 7A7 a. Now on permit/ATC it Dilferent.tban above l"Ung address City/state/sip a. Application tor: Xeita 3valuation 0 Improvement Permit/mc 0 Both e. system to services ,House 0 Mobile Home 0 Business 0 Industry 0 Other s. If Residence: # People # Bedrooms rA 3 # Bathrooms Dishwasher )�Oarbage Disposal , Hashing lisobias 0 Basement/plumbing 0 Basemant/No plumbing 6. 29 Business/Zn&=try/Ctherr speoity hype # people # sinks # comrades # showers # Urinals # hater Coolers IV r=83RVICl: # seats 3st:imat ed Yater Usage tvulons per da r) 7. Type of water supply: County/City 0 Well 0 Community a. Do yon anticipate additions or expansions of the 6eility this system Is Intended to serve? 0 Yes �No If yes,what type? ***IMPORTANT***CLIENTS MVST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BEIAW. Either a PLAT or SITE PLAN MULSTBESUBMITTED by the client with THIS APPLICATION. Property Dimensions: A JV9 �CAl-a- A4 WRITE D,ItREGTIONS(from MocksAle)to PROPERTY: Tax Office PIN: # S7 -7 —.S�5 f ,ys� 70 res 1 '0 l vo 0,r,,e - Aa Property Address: Road Name .&i Bale (/4) In as 7z7 City/Zip MAtolj U)trim3 Iain a Subdivision provide information,as follows: in4.0 G 9 Name: IIIA2014 U)obOs 62acAu/ qg Section: Block: Les 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,U the site plans or intended ase change,or if the information submitted in this application is falsified or changed I,also,understand that I am responsible for all charges Incamd front this application. 1,hereby,give consent to the Authorized Representative of the Davie County Haith 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 sultatft. �Q DATE 42 " 9 9 SIGNATURE /✓ . THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property lima and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: EAS: Account No. Revised DCHD(07/99) Invoice No. 1 a `J N c I' i 140' :D� 1 ` . O pip O d ( 44 t43 N IZ5 , 04 N 4-7lIp, i2() 114 1 bb Iv i Zo, J ^� s� J -1 Ito' �o4i Ppuo J n X 11 y 1 /I L DAVIE COUN'T'Y HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation • APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900025 Tax PIN/EH#: 5789-76-5851.45 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#45 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre Date Evaluated: z I{ Lop Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit / Cut FACTORS 1 2 3 4 5 6 7 Landscapeposition L L Slope% 31 HORIZON I DEPTH -(v Texture groupGL (_ Consistence SS SS Structure Mineralogy HORIZON 1I DEPTH — Texture group Consistence Vi SIV Structure c Mineralogy HORIZON III DEPTH q013—W Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence �f Structure IG Mineralogyl : I SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE O.4 /J SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: 6,LV OTHER(S)PRESENT: REMARKS: t j CQD 1J 1 Ohl ee P421 Z ca, 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)