202 Primose Rd Lot 10 CONSTRUCTION For Office Use only
' AUTHORIZATION *Cop File Number 122037- 1
Davie County Health Department County ID Number:G9-0•0-Do•010
f 210 Hospital Street Evaluated for: NEW
P.O.Box 848 Township:
Mocksville NC 27028' PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753.1680 0 6 / 2 8 / 2 0 1 8
Applicant: Dick Anderson Construction Property Owner. Dick Anderson Construction
Address: 225 Winghaven Lane Address: 225 Winghaven Lane
City: Mocksville Cly: Mocksville
State2ip: NC 27028 State0p: NC 27028
Phone#: (336)492-7579 Phone#: (336)492-7579
Property Location & Site Information
Address/Road#: Subdivision.-Ma hrnioods� Phase: L-Lot 10
u202 Primrose-Road
Fan- ---
Advance NC 27006 Directions
Structure: SINGLE FAMILY 1-40 to Hw 801 South Left on Peoples Creek Rd. Right
Old March R. Left on South March Rd. Left on Primrose
#of Bedrooms: 4
#of People: 3
'Water,Supply: PUBLIC
System Specifications
Minimum Trench Depth: 2 4
rnir,C'F
ssification: PS Inches
Minimum Soil Cover.
System? OYes QNo Inches
low: 4 8 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 3 Maximum Soil Cover: Inches
*System Classification/Description: *Distribution Type: GRAVITY-SERIAL
TYPE 11 A.COM/SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
_ 1 0 0 0 _ Gallons
*Proposed System: 25%REDUCTION. 1-Piece: OYes QNo
Pump Required: OYes QNo 0May Be Required
Nitrification Field
Sq.ft. Pump Tank: Gallons
No. Drain Lines 1-Piece: OYes ONo
Total Trench Length: 1 0 0 ft GPM—vs— ft. TDH
Trench Spacing:. _ OInches O.C. Dosing Volume: _ Gallons
Feet O.C.
Trench Width: Inches
_ - _ SFeet Grease Trap: Gallons
Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-II
Septic Tank Installer Grade Level Required: 01011 0111 OIV
Pagel of 3
CDP File Number 122037 - 1 County ID Number. G9-0.0-DO.010
` ❑ Open Pump System Sheet
Repair System Required:OYes ONO ONo, but has Available Space
epair System
Trench Spacing: Inches 0.
'Site Classification: PS — $ Feet O.C.
Trench Width: Q Inches
Design Flow: 4 8 0 — 2 4 8 Feet
Soil Application Rate: 0 - 3 Aggregate Depth: inches
'System Classification/Description: Minimum Trench Depth: 2 g Inches
TYPE 11 A CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. Inches
'Proposed System: 50%REDUCTION Maximum Trench Depth: 2 8 Inches
Maximum Soil Cover.
Nitrification Field Sq. Inches
ft.
No. Drain Lines 'Distribution Type: PRESSURE MANIFOLD
Total Trench Length: 2 6 6 ft Pump Required: QYes ONo OMay Be Required
Pre Treatment: O NSF OTS-1 OTS-II
'Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
"Permit Conditions
The issuance of this permit bythe Health Department in no way guarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements.
This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit not
to exceed five years,and maybe Issued at the sametime the Improvemerit Permit Issued(NCGS 13OA-336(b)).If the Installation has not been
completed during the period of Validity of the Construction Permit,the Information submitted In the application for a permit or Construction
Authorization Is found to have been Incorrect falsified or changed,or the site Is altered,the permit orConstrtrction Authorization shall became
Invalid,and may be suspended or revoked(.1937(8)).The person owning or controlling the system shall be responsible forassuring compliance
with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance,monitoring,reporting and repair
(1938(b)).
Applicant/Legal Reps.Signature Required? Oyes ONo
Applicant/Legal Reps. Signature* Date:
'Issued By: 2244-Daywalt,Andrew Date of Issue: 0 6 / 2 8 2 0 1 3
Authorized State Agent: WJMk Malfunction Log OYes
OHand Drawing Olmport Drawing Total Time:(H H:M M)
_ **Site Plan/Drawing attached.**
Page 2 of 3 0 1 .Hours_ 0 0 Minutes
S•8-CAS issued-new
CONSTRUCTION AUTHORIZATION
Davie County Health Department CDP File Number: 122037 - 1
210 Hospital Street G9-0.0-DO-010
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 0 6 / 2 8 / 2 0 1 3
Olnch
Drawing Drawing Type: Construction Authorization Scale: . OON/A k ft.
T_
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I I l i l l � l !_ i l ► I ! I ! I e�� _ l�� i - -I I I ----1 - I
1 � II � 1
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Daae 3 of 3
IMPROVEMENT PERMIT For Office Use Only
"CDP File Number 122037- 1
ftk�� Davie County Health Department
County ID Number:139-0-0-130-010
J
t 210 Hospital Street
r� r P.O. Box 848 Evaluated For: NEW
Mocksville NC 27028 To:Mnship:
Phone:336-753-6780 Fax:336-753-1680
PERMIT VALID UNTIL: 6/28/2018
"NOTE TO INSPECTIONS DIVISION: Building Permits cannot be Issued with this Improvement Permit.
r
plicant: Dick Anderson Construction FAddress:
er: Dick Anderson Construction
ddress: 225 Winghaven Lane 225 Winghaven Lane
ity Mocksville Mocksville
State/Zip: NC 27028 State2ip: NC 27028
Phone : (336)492-7579 Phone (336)492-7579
Property Location & Site Information
Address/Road : Subdivision: Marchwoods Phase: Lot: 10
202 Primrose Road
Advance NC 27006 Directions
Structure: SINGLE FAMILY 140 to Hw 801 South Left on Peoples Creek Rd.
of Bedrooms: 4 Right Old March R. Left on South March Rd. Left on
of People: 3
Primrose
'Water Supply: PUBLIC
nital System
System Specifications
sst Katgn:
PS
Minimum Trench Depth: 2 4 Inches
Saprolite System? QYes QNo Maximum Trench Depth: 3 6
Inches
Design Flow:
4 . 8 0 Septic Tank;
1 0 0 0 Gallons
Soil Application Rate: 0 3 1-Piece: QYes QNo
Pump Required: QYes ()No OMay Be Required
'System Classification/Description:
TYPE II A.CONY SYSTEM(SINGLE•FA IILY OR 480 GPD OR Pump Tank: Gallons
LESS)
'Proposed System; z5°o REDUCTION 1-Piece: QYes QNo
Repair System Required:QYes ONo ONO, but has Available Space
Repair System
'Site Classification: PS tAinimum Trench Depth: 2 8 Inches
Soil Application Rate: U - 3 Maximum Trench Depth: 2 8 Inches
C
u
`System Classification/Description: Pump Required: QYes QNo Q May be Required
TYPE 11 A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR
LESS)
'Proposed System: 50',oREouCTION
Page 1 of 3
COP File Number 122037 - 1 County ID Number: G9-0.0-DO.010
*Site Modifications ❑ Open Fill Sheet
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
!Permit Conditions
The issuance of this permit by the Health Department in no way guarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements.
Site Plan The improvement Permit shall be valid for 5 years from date of issue with a site plan(means a drawing not necessarily drawn to
O scale that shows the existing and proposed property lines with dimensions,the location of the facility and appurtenances,the
site for the proposed Wastewater system,and the location of water supplies and surface waters).
Plat The Improvement Permit shall be valid without expiration with plat(means a property surveyed prepared by a registered land
O surveyor,drawn to a scale atone Inch equals no more than 60 feet,that Includes:the specific location of the proposed facility
and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters. Plat
also means,for subdivision lots approved by the local planning authority and recorded with the county register of deeds,a copy
of the recorded subdivisions plat that Is accompanied by a site plan that is drawn to scale).
The Department and Local Health Department may impose conditions on the issuance and may revoke the permits for failure of
the system to satisfy the conditions,the rules,or this article.This permit is subject to revocation if the site plan,plat,or intended
use changes(NCGS 13OA-335(1)).The person owning or controlling the system shall be responsive for assuring compliance
with the laws,rules,and permit conditions regarding system location,installation,operation,maintenance,monitoring,
reporting,and repair(.1938(b)).
Applicant'Legal Reps. Signature Required? Oyes ONO
Applicant/Legal Reps. Signature: Date:
'Issued By: 2244-Daywalt.Andrew Date of Issue: 0 6 2 8 2 0 1 3
Authorized State Agent: A2 MAU
OValid without Expiration?
OCreate CA.
OHand Drawing Olmport Drawing
**Site Plan/Drawing attached.** Total Time:(H1-111f,t)
0 1 Hours 0 0 Minutes
Page 2 of 3
Activitv Code: S-4-IFS issued.new,valid for 60 mos.
IMPROVEMENT PERMIT
Davie County Health Department CDP File Number: 122037 - 1
210 Hospital Street
County File Number: G9-0.0-DO-010
P.O.Box 848
hlocksville NC 27028 Date:
Oinch
OB
Drawing Drawing Type: Improvement Permit Scale: , ' ON/A k _ •ft.
O
....._.. _... ... ... .. .. _;-......., _. .. . _ _. fib. _
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Page 3 of 3
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Environmental Health
PA ,N6WW--- P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)7534780/Fax(336)753-1680
Application For: Site Evaluation/Improvement Permit ❑Authorization To Construct(ATC) ❑ Both
Type of Application: R ITew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION.BULLETIN for instructions.
APPLICANT INFORMATION
Name D CD Contact Person
Address f/ Home PhoneC354 1 (/?.t 1S^7 9
City/State/ZIP LMA S 1Z 14 GG C 7 Business Phone1J3G,) X92 7 Z 751_
Email
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Comers Flagged e7
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
(Permit is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name 'pick A.,b g g-SD IV Phone Numberr; ,moo f-/FP- ;"
Owner's Address A City/State/Zip IydGr US 1GL�i C vz� f�
Property Address 26 2 MAI Re SE" ''R q. ----Cityi4 6dANC�'
Lot Size 1,D ?2 4e, Tax PIN#
Subdivision Name(if applicable) ld-P G Section/Lot#
Directions To Site: L p o,
If the answer to any of the following questions is"Yes",supporting doc�ytation must be attached:
Are there any existing wastewater systems on the site? Yes o
Does the site contain jurisdictional wetlands? Yes /leo
Are there any easements or right-of-ways on the site? �s No
Is the site subject to approval by another public agency? Yes
Will wastewater other than domestic sewage be generated? Yes _.�;iqo—
TF RF,S1DF,NCF.FU J,OI JT THF,BOX BELOW
#People 3 #Bedrooms 9F #Bathrooms c3 Yz Garden Tub/Whirlpool ❑Yes ❑No
Basement: ❑Yes R<n Basement Plumbing: ❑Yes ❑No
• 7F NON-RFSIDF,NCE FILL OUT THE BOX BELOW
Type of Facility/Business Total Square Footage of Building #People
# Sinks #Commodes # Showers #Urinals
Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY:# Seats
Type system requested: C36onventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: Cf County/City.Water ❑New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes R No
If yes,what type?
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that
any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if
the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized Representative
of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules.
I understod that I am responsible for the proper identification and labeling of property lines and comers and locating and flagging
or a houselity!9eftigoroposed.well location and the location of any other amenities.
Site Revisit Charge
Pr perty owner's or owner's legal representative signature
Date(s):
Client Notification Date:
Date EHS:
�� lzzo37 .
Sign given ❑Yes ❑No Account#
Revised 11/06 Invoice#
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APPLICA LIMY FOR SITE EYAUJAT)ON/tNPROVEWea PER.NIT R ATC
Davit,County Health DepadM9nt i
EnylivrrmenblXea/tl7Sedion
P.O. Box aie/zlo Hospital Street
' MocJravi3;4. I+C Z793$
(336)751-8760
...MWATANT... TRIS "PLICLTX0X CAMUr BF PSOCSSSED MOXIS ALL 7= RRpOIRRD
%wPO=&T=SS YpDV==.. Refer to the na'OIODIYION BOLLRT= for instructions. •,
✓1. Was. to be Biu-& !�H/1/�G7� 'j/)�.�S�1.v1G c e—tect s.r.on /D/r', e STN_. -S dA)
./Iratiing A&dsssa �/A/�rH G�.•lf ZN c.—w—o rhea. �7C�"75�9
✓city/auta/Z2z' rrer�(�rst//[�.E ill(' .;t?038' ✓asasaasa Phone q,? —7.;.7-j
l�2. Nme.ou PomIc/ASC if IlLMor.rt tam Above
11.11tnq&Adze&& City/scut/asp
,-2. Application For. x5ita, Evaluation 0 Ixprov®eat permit/ASC 0 Both
,—A. oyrt...to ser+sae. nou&e ❑ mobil. coma ❑ Business d sndustry ❑ outer
--s. tyy. r.t-requested. C Caa••.ntlooal L7 eoa..etional eodiriad t3 imwusw
�i. ,I,f/kkeesidencei�/I People 13adrocros _ B Bathrooms
-i' iQDlStu...Mr 170.rb.Be Dt.se"al I/M..kiy 7(aaAL. ❑Buer.vrlu.�teg ❑su....etAN slrbswq
7. It Hada.../Industry/Cthar, verify type t People B Stake
/ Commas a E]arera I urinals a Vatar Cna2.ra
Id rWDSXRVXCBt 0 Sosts l-ti sted Matic; IIsagB (yallmg per dy)
-I. Type of water mvp2y. U-Coua:y/City 13 Well O Co®uaity,
s. Do you aeticlpata addition&or expansions of the facility this system is intruded to serve?O Yes crf a
Ifycs.whatt "
IMPORTiW7" CLtCtrt'iMUSTCD PLETETHE RE12UIREDPROPERTY INFORMATION REQUESTED
-.11 EfthvaPLATerSITtiPI �rYTBESV3Mf77EDb the client stith THIS APPLICATION.
tf3lropCrfyDimensions .Q{,eJ%-WRiTEDIRELTtONS(frainMocksvme)toPROPERTY.
C--Tax office PIM: a 78 7 6 ./3 t58 lrGi �bI e.-S C-Z4+G1<
_.Propertypddrr.: 99adName l�Pe'eS CREee-le
CItyPLp 4Q VA tJ CE AIC A70,X
f fn a Subdivir en ravldc Informat(aot a3 fcllowr.
Marne: 2C/1&)4nn c A099,E LA
Section: Block: Lon-44" e-trate home corners Gagged: �2AGtfa � J�6tC IQ "'-C'
This is to certify that the ittrormatloa provided Is correct to the best army knowledge.I understand Utat•sny pmall(s)
issued hereafter are subject to suspension or ttvoaQoo,if the sUe pians or intended use change,or if the infornution
submitted to this application is fatsifird or elt:occ%L 1,rtlso,tm�rrsrgnd;her f rrm respon:fbfsjor ell cLarra inrnrrrd from
f fs opplicadom 4 hereby,give consent to the Authorized Reprewntntive of the Davie County Health Department
to cater upon above described properh•located in Davie County and owned by
to conduct all tesntin;procedures as necessary to determine the site sul
t--DATE g, -eR.1 - O S "SIGNATURE
THIS AREA MAY BE USED FOR Df,kWB(C YOUR SIZE PLAN(Include all of the fallowing: Existing and proposed
property lines and dlmcusloost structures.setbacks, and septic locations).
Site Revisit Charge
Datc(s):
Client Notitltalian Date:
EHS: ¢
Sign given 6 Account No.
it"ised DCHD(05!03 Invoice Ma __
.. ti DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
--Ccz'aUj IL I+.- UUUUUZ285 Tax PIN/EH#: 5789-97-0344.13
r Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Phase 4 Lot# 13
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 l 3 4 5 6 7
Landscape 2osition
Slope%
HORIZON I DEPTH O
Texture group <f L
Consistence r
Structure
Mineralogy
HORIZON I1 DEPTH 2
Texture group _
Consistence
Structure S
Mineralogy
HORIZON III DEPTH
Texture group + C�
Consistence to
Structure
Mineralogy
HORIZON IV DEPTH 'S3
Texture group S'CL+ S1 'TCL
Consistence SS
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
1exture
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 , VF1-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-Prisrpatic
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/
Classification-S(suitable),PS(provisionally suitable),U(ursuitable)
LTAR-Long-term acceptance rate gal/day/ft ;,