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197 March Ferry RdLot 32 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section .+. -t _ P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900025 Tax PIN/EH#: 5789-76-5851.32 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#32 Reference Name:. Dick Anderson Location/Address: Peoples Creek Road 27028 Proposed Facility: Residence Property Size: 1 Acre ATC N%nb7r: 2610 **NOTE** "Phis mprovement/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 oliC�� Dishwasher: Ef"" Garbage Disposal:e Washing Machine:�� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift 9#Seeats Industrial Waste: ❑ Lot Size �C Type Water Supply el D Design Wastewater Flow(GPD) Site:.Newer Repair❑ System Specifications: Tank Size 20 GAL. Pump Tank GAL. Trench Width,1,6'- Rock Deptb.p4t Linear Ft; Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISERS)IF 6 K 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 day of installation. Telephone#is(336)751-8760.**** F Environmental Health Specialist's Signature: Date:Z�- 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 M 5789-76-5851.32 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#32 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number. 2610 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 WASTEWATER S UCTION IS VALID FO 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. Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) APPUCATION FOR SITE EVAt RTiON/IMPROVEMENt PERMR&ATC r [E @ IEa W/ IE Davie County Health Department D Envftnmental Health Section P.O. Box 848/210 Hospital Street (lE_i; 719J9 • Mocksville, NC 27028 (336)751-8760 *eS!lPt7titT?iNT*** THIS APPLICATION C#I Wr BY ==583D V=811 WZ THE REQUIRED I1WOM ATION IS PROVIDZD. Refer to the XMVF ZXCN BULLETIN for instructions. 1. Nome to be Billed Acle 4AIxy-c 2beN'CnA)a7' Contact Person D1C1e-,41fVA4A0x) Nailing Address A A SyJ1N a 14Ay" L A1j sod. Whom. 5`9A- 7 57.9 city/stat./siP It'[OCIGF,y1Lt�. N. C. Q7oA9 Business Whoa. 999 7at.7f s. xame on Permit/ATC it different.then above Nailing Address City/state/sip 16-.13- a. Application For: Site =valuation improvement Permit/ATC 0 Both e. systen to servioes ,House 0 Mobile Home 0 Business 0 Industry 0 Other 5. If Residenoe: # People Bedrooms /YI_r 3 e Bathrooms Dishwasher )�oarbape Disposal J u W"Uns Haohiae 0 Eement/Plumbing 0 Bassmant/Ho Plumbing su 6. tf sineseAndustry/Others specify +typla # People f Sinks # commodes # showers # urinals # water Coolers It TOODSERVICS: # Seats Zstimated Water Usage (gallons per dais) z. Type of nater supply: 'County/City 0 Well. 0 Community a. Do you anticipate additions or expansions of the facility this system Is intended to serve? 0 Yes �No If yes,what type? ***IMPORTANT"**CUENTS M[ISTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESM BEIAW. Either a PLAT or SITE PLAN M1WBESLZWTTBD by the client with THIS APPUCATION. Property Dimensions: AA�/Lb /- �.Aems.rte, IWRITE DIRECTIONS(from MoclsAle)to PROPERTY: Tax Office PIN: # SZ -s� �l��2/ O TO FSO j QO �il: I � Property Address: Road Name ('ISE/C - L SFT (/ ) /Y11 LZ 7-b City/ZIp LU=LM 3 If In a Subdivision provide information,as follows: 1n4,D G 9 Name: A &C,4 U)0610--% e?220ZJl& /_tP.gB Section: Block: Lots .�� Date Property Flagged: This is to certify that the information provided Is correct to the best of my knowledge. I understand that any permits) Issued hereafter are subject to suspension or revocation,if the site plans or intended ase change,or if the information submitted in this application is falsified or changed 1,also,understand that I ani responsible for ail charges Incurred from this appllcadon. 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 sultab DATE 1A-) " '-? 9 SIGNATURE /✓ . THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(include all of the following: Existing and proposed property Unes and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): \ Client Notification Date: \ ` ERS: 1� Account NO. O � Revised DCHD(07/99) Invoice No. 2 �d 3 --7 N - -mss u-�..•��o:�,��.. IAc�• � I ; �i is N 42 i k43 ( 44 � J ee l n J 125 os 47 jQ lzs- r '►Q o �v goo' � U c� Ito i2 1p =1 x I _ 05� f J {" r DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900025 Tax PIN/EH#: 5789-76-5851.32 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#32 Reference Name: Dick Anderson Location/Address: Peoples Creek Road 27028 Proposed Facility: Residence Property Size: 1 Acre Date Evaluated: LI�pQ Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit ll_� Cut FACTORS 1 3 4 5 6 7 Landsca osition Slo % ellHORIZON I DEPTHj,2 ' Texture group Consistence Structure Mineralogy HORIZON II DEPTH y r Texture groupG Consistence i Structure /j 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 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) LIAR-Long-term acceptance rate-gal/day/ft2 DCHD 05/99(Revised)