227 Old March Rd Lot 49 DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Strut — -
Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
OPERATION PERMIT
Account M 989900025 Tax PIN/EH M 5789-77-4010
Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#49
Reference Name: LocationiAddress: 227 Old March Road-27006
Proposed Facility: Residence Property Size:
ATC Number: 5085
**NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC has been installed
in compliance with Article I 1 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. C'
System Type: S.T.Manufacturer Tank Date Tank Size
Pump Tank Size
System Installed By: Ili 4 44 ie E.H.Specialist: ate:_
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DCHD 11/06(R vised)
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DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 989900025 Tax PIN/EH#: 5789-77-4010
Billed To: Dick Anderson Construction Subdivision Info: Marchwoods. Lot#49
Reference Name: LocationiAddress: 227 Old March Road-27006
Proposed Facility: Residence Property Size:
ATC Number: 5085 Site Type: ew ❑Repair ❑Expansion
**NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A
Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat
or the intended use change.
Residential Specifications: #Bedrooms #Bathrooms L.J #People Basement3'] asement plumbing R—
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size Q- Type of Water Supply: B ounty/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow(GPD)3(oto Tank Size 1)0 —tJAL.Pump Tank GAL. �
d Trench Width 3�1 Max.Trench Depth 3 G 41RockDepth I a- Linear Ft. �3 b
As stated in 15A NCAC 18A.1969(5)
Site Modifications/Conditions/Other: asseptod System-- rnav ai4n he [IsE
hContact the Davie County Environmental Health Section for final inspection of this system between
\' 8:30—9:30a.m.on the day of installation. Telephone#(336)751-8760.
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Environmental Health Specialist Date:
DCHD 11/06(Revised)
Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax(336)753-1680
IMPROVEMENT PERMIT
Account #: 989900025 Tax PIN/EH#: 5789-77-4010
Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#49
Address: .225 Wing Haven Lane Location/Address: 227 Old March Road-27006
City: Mocksville Property Size:
Reference Name:
Proposed Facility: Residence
**NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An
Authorization To Construct a wastewater system must be obtained from this office prior to the
construction/installation of a wastewater system or the issuance of a building permit(in compliance with
Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to
revocation if site plans,plat or the intended use change. f
Permit Type: R<ew ❑Repair ❑Expansion Permit Valid for: Years ❑No Expiration
Residential Specifications: #Bedrooms #Bathrooms �!.- #People BasementCgasement plumbing
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD):3' Type of Water Supply: 96unty/City ❑Well ❑Community Well
Site Modifications/Permit Conditions: As stater! in 15A NCAC 18A.1969(5�
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Environmental Health Specialist Date
i.p.11-06
K11AY
C E O V E
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIDavie County Eavir omental Health 1 4 2010
P.O.Bax sallalo Hospital street
Mocksville,NC 2)M
// (336y7Si-67801 Fax(336)753-1680 Q�MRONMENTAL HEALTH
Apptication For. 114c aluationArnprovement Permit C Authorization To ConshW(ATC) t DAVIE COUNTY
Type of Application: =Jew System =1Repair to Existing System OExpansim Modification of Existing system or Facility
••9IMPORTAN70•0 THIS APPLICATION CANNOT85PROCESS£D UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Ria to the INFORMATION BULLETIN for insUvctior&
APPLICANT INFORMATION
Name to be Billed lic:4 A}4d6RSa o Contact Pelson
Billing Address e v J 4) LAas Home Phone A4 I.-
D&
D218 Business Phone 3. ia T15 22-72
Name on Pett =ATC ifDiTereid thats Above
Mailing Address City/StatdZip
PROPERTY INFORMATION "Date HousdFa ffi Coursers Fl ed
NOTE: A survey plat ar site plan mist accompany this application. Included:IS Site Plan I-Mat(toscale)
owner'sName b����is valid for 60 morahs with site plan expiraaon with wr>pktc ply Phone Nttntl�er 33 99$7L7q
Owner's Address =17 t 6 i Citymi-e Z Atoe1XVt We-
Property Address city *d 0A t 2 o.e..
Lot Size &*Qui, At Tax PINK 4C7.0 V721 401a
Subdivision Name(if applicable) W til
Directions To Site; O
If the answerto any of the fotlov iog questions is"yes".supporting dommentation must be attached
Are there any adsting wastewater systems an the site? 3Yes MSO
Does the site contain jurisdictional wetlands? tlYes M40
Are there any easements or right-of-ways on the site? UYes Wo
Is the site subject to approval by another public agency? Oyes
Will wastewater other than domestic sewage be enerated? f_I Yes WK
IF RESIDENCE FILL OUT THE BOX BELOW
N People�_ #Bedrooms T M Bathrooms Z.V Garden Tub/Whirlpool es -No
Basemen lies LINO Basement m : Vfcs 13No
IF NON RESIDENCE FILL OUT THE BOX BEW W
Type of Facility/Business Total Square Footage of Building N People
k Sinks 6 Cottnnodcs g Showers 0 Urinals
Estimated Wen Usage(gallons per day) (Attach documentation of similar facility,water constmnption)
FOODSERVICE ONLY: A Scats
Type system requested: UeSaventional BAccepted Elnmovative OAlterntttive OOdter
Water Supply TypeSKoumy/City Water .No.%v well •'IEtrisring well J Community Well
Do you anticipate additions or expansions of the faeility this system is intended to serve7 L'Yes
If yes,what type?
This is to a:r*That tie information provided on Misapplication is true and correct to the best of ray knowledge. I understand
that any permit(s)or ATC(s)issued here l erare subject to suspension or revocation if the site is altered,the intended use
c ungm or if the information submitted in this application is falsified or changed. I hereby grunt right ofentry to the Authorized
Representative of the Davie County Health Department w conduct necessary inspections to determine compliance with applicable
laws and rules. I understand that 1 am responsible for the proper identification and labeling of property tines and corners and
Ioca�nRgrjd f 'n m o hoosr/faeility 1
on.proposed well location and the location of any other tunenidcs.
Property owner's or owriies legal representative signature Site Revisit Chargee
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Client Chew
� Notification Date:
Daft EHS:
Sign given OYes DNo Account a f9 Q0 d l
Revised 11.106 Invoice A
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I r'1 i• l ,;P , • r.i.'�.i}.S. PLAT MAP Of PHASE 31
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1'1'/'t /,t DICK ANDERSON CONST. CO.
80 WAC WAU UN
•31. ,' ' 1-711
f ,• ` �� tOv,O a.. ,' ` �)Lt $MACY OROrt TOWNSHIP
.� )• DAVIE COUNTY.MoRTN CAROLINA
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�,. APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT& O
Davie County Health Department
Environmental Health Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028 MAY 5 2042
(336)751-8760
ENV!
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS AL EALTH
INFORMATION IS PROVIDED. Refer tof the INFORMATION BULLETIN for instrucnt3.o
1. Name to be Billed _-0J61e 4oU4t2�d A 1A,
"L 10AJS7 -�-Z r_ Contact Person 1)10e lyAJa!jl 7.G)
Mailing Address vZ a _� C(/l.tl G //-A,45;; Z,0 Home Phone '7 � -7 7
City/State/ZIP I��GS✓/c-z _ �(/,�. 70� Business Phone ��- 7-17 `%
2. Name on Permit/ATC if Different than Above
Mailing Address Ci Statepylye T
A IIz((�/1t�Vj
3. Application For: X Site Evaluation Improvement Permit/ATC n Both
4. System to Service: 'House ❑ Mobile Home D Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms -2)— # Bathrooms of /-I'-
Ll
,/LI Dishwasher LI Garbage Disposal LI Washing Machine LI Basement/Plumbing II Basement/No Plumbing
6. If Business/Industry/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: County/City ❑ Well ❑ Community
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No
�./ If yes,what type?
***IMPORTANT'CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQU TED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
TH!S I
Property Dimensions: '7-0 WRITE DIRECTIONS(from Mocksville)to MtOPERIT:
y
Tax Office PIN: # 5'7 0 9^7 9-58 5). 1/7 nn
Property Address: Road Name 06!Q /1?A2cay 4 /-0 /�moC�cs✓icc f � �d"a'UCc �.dw y /
City/zip 40VL7.tucz . 7.7006 LFA,– oAU "e4
If in a Subdivision provide information,as follows: ,TO oo o 5 o.y 2;r--
Name: MAALP c t bQ191
Section: ""IA Block:N/►9. Lot: 9 Date Property Flagged: AwV 6 714
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 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 froru
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 suita
DATE 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
Datc(s):
Client Notification Date:
EHS:
Account No. 7 Doo 5-
Revised
Revised DCHD(07/99) Invoice No. ' 0 -0
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
SoiVSite Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 989900025 Tax PIN/EH#: 5789-79-5851.49
Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#49
Reference Name: Location/Address: Old March Road-2700/9
Proposed Facility: Residence Property Size: see map Date Evaluated: O
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit j/' Cut
FACTORS 12 3 4 5 6 7
Landscape position
Slope%
HORIZON I DEPTH
Texture group SL
Consistence
Structure 41(
Mineralogy 5 '' r/`
HORIZON II DEPTH
Texture group
Consistence i
Structure /C
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
Mois
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)