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224 Old March Road Lot 65 ` 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#: 5789-79-5851.65 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#65 Reference Name: Location/Address: Old March Road-27006 Proposed Facility Residence Property Size: see map ATC Number: 3862 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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: 1`//� Date: 4 ,3 room s 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. F o� Septic System Installed By: ZorE' Environmental Health Specialist's 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 IMPROVEMENT/OPERATION PERMIT Account M 989900025 Tax PIN/EH#: 5789-79-5851.65 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#65 Reference Name: Location/Address: Old March Road-27006 Proposed Facility Residence Property Size: see map ATC Number: 3862 **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 -,-7 #Baths Dishwasher Garbage Disposal:❑ Washing Machin Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type 13�!#People #People/Shift #Seats Industrial Waste: Lot Size Type Water Supply Cy Design Wastewater Flow(GPD)<,� Site: New.O"—Repair❑ System Specifications: Tank Size,"GAL. Pump Tank GAL. Trench Width r , Rock DepthOLL_ Linear FtJi�o Other: Required Site Modifications/Conditions: IMPROVEi11ENT/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 day of installation. Telephone#is(336)751-8760.**** Y' Environmental Health Specialist's'Signature: �►'// Date: DCHD 05/99(Revised) _ -'C APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT& Davie County Health Department EnVifVftmwtai Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028AY ' 5 Z�Q2 + (336)751-8760 INVI ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS AL 07J . , G1(TH INFORMATION IS PRROVIDED. Refer to the INFORMATION BULLETIN for inst-ru/c/Jt3.o 1. Name to bo Billed �jC/c' t�,yrJrt�yy� ( f2A)Sj -Ldr,_ Contact Person ��/CJS fy�/rl f d Ll Mailing Address j-R.Q '� aJIAI G- G,0 Home Phone -7E'-7 City/State/ZIP /v/(xfGs1//C�r_ �l_(!. 70� Business Phone IS- 7-A 7 2. Name on Permit/ATC if Different than Above Mailing Address ;Ci te/ 'pI 3. Application For: X Site Evaluation v ent Permit/ATC 11 Both 4. System to Service: l/House ❑ Mobile Home ❑ Business ❑ Industry U Other 1 5. If Residence: # People # Bedrooms -2) _ # Bathrooms D /-I- 1.1 Dishwasher LI Garbage Disposal LI Washing Machine L1 Basement/Plumbing 11 Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks N Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: ## Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City ❑ Well I1 Community UDo you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes U No . If yes,what type? ***IMPORTANT***CLIENTS MUSTCOMPLLTETHE REQUIRED PROPERTY INFORMATION REQU ITD BELOW. Either a PLAT or SITE PLAN MUSTBESUBAMITTED by the client with THIS APPLICATION. (Glia� , /�" \L Property Dimensions: 34 TO ,�C/1�� r� WRITE DIRECTIONS(fron,Moduiville) to I'ROI'ERTY: Tax Office PIN: # 5 7 0- 2-7 1-59 Q. Gs Property Address: Road Name UGb 411g2CW City/Zip 1q0VA7iUCr- . :2-7o0G Lt-A,— z)4) .en C/)sYt/cLc If in a Subdivision provide information,as follows: n 474.oeCly U/00/),5 o.t)2r- Name: /6��y2C/� (�t.Coo-s' f /1445 3 Section: �la Block:N�►�4 Lot: 6 5 Uate Property Flagged: 4)iF/C O This is to certify that the information provided is correct to the best of my knowledge. 1 understand that any permits) issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or if the information submitted in this application is falsified or changed. I,also,understand that I am responsible for all charges incurred from this application. 1,hereby,give consent to the Authorized Representative of the Davie County Ilealth Delmrtmcnl to enter upon above described property located in Davie County and owned by _ to conduct all testing procedures as necessary to determine the site=X—� r4� DATE 6 — O �. SIGNATURE /D)_ W-CA Q� 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. y 7 Doo S Revised DCIiD(07/99) Invoice No. a©a '-4 a ~ . . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900025 Tax PIN/EH#: 5789-79-5851.65 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#65 Reference Name: Location/Address: Old March Road-27006_ � Proposed Facility: Residence Property Size: see map Date Evaluated: Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut 4 FACTORS 1 2 3 4 5 6 7 Landscape position .L .L Slope% HORIZON I DEPTH •� �� Texture group X_ / 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 / ff SITE CLASSIFICATION: 14� 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 05/99(Revised)