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229 March Ferry Rd Lot 35 ,. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028L— (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900025 Tax PIN/EH#: 5789-76-5851.35 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#35 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility:- Residence Property Size: 1 Acre ATC Number: 3209 **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 #Baths Dishwasher:Garbage Disposal: ❑ Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste:❑ Lot Size Type Water Supply C Design Wastewater Flow(GPD) CV Site: Nevem Repair❑ c � System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width�/Rock Depth ° y/Linear Ft )OU Other: Required Site Modifications/Conditions: IMPROVEMENT/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.**** GU Pst r- 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#: 5789-76-5851.35 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#35 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number: 3209 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 WASTEWAT ON TRC NIS VA FO A 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. rf Septic System Installed By: Environmental Health Specialist's Signature: Date:�— DCHD 05/99(Revised) APPUCATION FOR SRE EVAUTATiON/IMPROVEMEM PERMIT do ATC r r, . , Davie County Health Department D Environmental Health Se+clfM P.O. Bos 848/210 Hospital Street DEG 71999 Mockaville, NC 27028 (336)751-8760 ***Z1HpORTANT*** THI8 APPLICATION t�INNOT BE PROCSB=D UNLESS ALL THE REQUIRED INIi'OZWIOH IS PrROVIDRD. Refer to the IN3'O=TION BULLETIN for instructions. 1. Naar to be Billed iIKG 14 "a-cas6oy 6A)z,y- Contact parson Hailing Address oA A S W iN o•14A &.W LAI ams phone yl;k- 7 5 7 9 city/stat•/sip aec,/C VIt,t..-. Al. C. Q70Afr Business whom 1999'- 7A7? 2. Now on pecan/ATC it Different.than Above Hailing Address City/state/alp 3. Application tor: Xsits Evaluation 0 Improvement Permit/ATC O Both t. states to services House 0 Mobile Home 0 Business 0 Industry 0 Other 5. If Residence: 4 People 4 Bedrooms AlySru/ Bathrooms Dishwasher I/Oarbage Disposal }(Washing seachine 13 Basement/plumbiag D Baseaent/Ro, plumbing S. i! Business/Industry/Others specify t`y`pe i people 4 slake 4 Commodes 4 showers 4 Urinals 4 Water Coolers i! TOODSERVIC3: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: county/City 0 Well 0 community e. Do you anticipate additions or expansions of the facility this system Is intended to serve? 0 Yes �No If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBSHTTED by the client with THIS APPUCATION. Property Dimensions: AAVXQ 4 4AWRTTE DIRECTIONS(from Mocknville)to PROPERTY: Tax Office PIN: # SZ S-J — a� ,3`�/� 10 70 Ta SSo 19-o Ai e�8 Property Address: Road Name &Xea/C - LEFT (/ /yI!lacs ?D City/Zip MA)eCq t0==3, If in a Subdivision provide Information,as follows. 1444 G 9 Name: MAR-0-4 t t)06D.5 ABEL1A98 Section: Block: Lots Date Property Finned: 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 ase change,or if the Information submitted in this application Is falsified or changed„ 1,also,understand that I ares responsible for all charges Incurred frons this applicadom I,hereby,gave 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 snitab DATE I Z " CI '9 SIGNATURE /✓�Q•�46r-, THIS AREA MAY BE USED FOR DRAWING YOUR STTE PLAN(Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revbit Charge Datc(s): Client Notification Date: EAS: Account No. Revised DCHD(07/99) Invoice No. a 3 0�L( LI/ �� 3—7-0 ,-- rtitio I 19>' 14U' 140' V � N N 1 8 had 120 1�S 00' w 74 li rz Zop' I"TD� f f I DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900025 Tax PIN/EH#: 5789-76-5851.35 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#35 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27028 Proposed Facility: Residence Property Size: 1 Acre Date Evaluated: :;,9 �.L'P1D Water Supply: On-Site Well Community Publicy Evaluation By: Auger Boring Pity Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope% HORIZON I DEPTH // Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group G 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 / SITE CLASSIFICATION: EVALUATION BY: G LONG-TERM ACCEPTANCE RATE: / OTHER(S)PRESENT: REMARKS: u 6P j&"'j 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) tAI T020 CDP DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST n APPLICATION IP/ATC OSWW REPAIR q Name�j 14 —0'e- I�t t�5 e-�� Telephone Number l 41 e/ -736 Address q c: P� ,P -2 e5)Qelo Mailing A dress (if different from above) Email Address: Subdivision Name - 1-5 p h3u 2 �rLot# 3 S A :L Directions j` s r 41 Date System Installed dOO ? Name System I stalled Under Type Facility 51- Number Bedrooms_— Number People Served Type Water Supply 4 6 Specific Problem Occurring Date Requested / 3! — /2 Info Taken By O cz ZC74Q s-, THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY KNOWLEDGE,AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED FROM THIS APPLICATION. Signature of owner or Authorized Agent Initial Fee Date REHS Revisit Charge Date Reason Revised 2-2011