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248 Old March Rd Lot 62 '�, `. • 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#: 5789-79-5851.62 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#62 Reference Name: Location/Address: Old March Road-27006 Proposed Facility Residence Property Size: see map ATC Number: 3983 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: A2 2/ Dater Z7 CERTIFICATE OF COMPLETION _7,`d 07 /11l4&F **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permix� 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 y given period of time. r� F7 �0 � / ' '16C ` t. 9 raD Ck Septic System Installed By: Environmental Health Specialist's Signature DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT a• _ Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900025 Tax PIN/EH M 5789-79-5851.62 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#62 Reference Name: Location/Address: Old March Road-27006 Proposed Facility Residence Property Size: see map ATC Number: 3983 **NOTE**This Improvement/Operation Permit DOES NOT authorize the construction of 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 Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow(GPD)� Site: New 2Repair❑ System Specifications: Tank Size/ODD GAL. Pump Tank GAL. Trench Width��"Rock Depth/4Linear Ft.,&D Other: acC )RudAS.stato 5n 15A NCAC 18AA969(5) Required Site Modifications/Conditions: vtems rr v al-0.0 ba imno 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. :30 p.m.on the da tallation. Telephone#is(336)751-8760.**** O-7 lob JU s K C_ 1'c,,,,,4 LA, b-e- 5d L,(Obe_j a Environmental Health Specialist's Si ature: Date: DCHD 05/99(Revised) •C. . .. APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT& ((a Davie County Health Department EnviRvnmeatal Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 ��Y ' 5 2002 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS AL %QT(! G1[Til INFORMATION IS PRROVIDED. Refer to the INFOR/MATION BULLETIN for instruc/]tio 1. Name to be Billed -12451c- -4W1)��d'0 rOAJSi Contact Person ��/CJS f-1(l1'�at S .Ll Mailing Address ; ��nS OJIV G- /�j�jLac%�Z"-) Home Phone �j�%ca' -7 '7 City/state/ZIP /v/(x%GSL//tom r �l,�. 70� Business Phone - -)-A 7 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip V/ kflr 3. Application For: Site Evaluationoe I��ro �ent Permit/ATC Il Both 4. System to Service: I/House ❑ Mobile Home ❑ Business U Industry U Other ) 5. If Residence: # People # Bedrooms _ # Bathrooms 41,- Ll -,/LI Dishwasher LI Garbage Disposal LI Washing Machine U Basement/Plumbing II Basement-/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # showers # Urinals # Water Coolers IF FOODSERVICE: It Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City ❑ Well II Community Do you anticipate additions or expansions of the facility this system is intended to serve? U Yes U No If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQU 'I'EI) BELOW. Either a PLAT or SITE PLAN MUSTBESUBMITTED by the client witli THIS APPLICATION. G1�a /u- 4 Property Dimensions: j% Tb WRITE DIRECTIONS(from 11'loclssvillc)to I'110I'1?K'I'1': J y Tax Office PIN: g 5 7 0 9_7 q--S9 S) Property Address: Road Name Oe-0 1711g2Cw /20 / locics✓iuG �� /7�J'df1oV Cc" ,. qw 6 City/Zip 40y4itJU= , 2700(, L6A,— o.0 C�4 If in a Subdivision provide information,as follows: 77Z InK CCl-I U1001-) o.y 2r Name: / 4 y24/-f UbQt01 Section: )"IA Block:N�►'�} Lot: � 2 Oate Property Flagged: 4) O This is to certify that the information provided is correct to the best of my knowledge. 1 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 fur all charges incurred from this application. 1,hereby,give consent to the Authorized Representative of the Davie County I-leallh Departmellt 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 �p DATE O ol. z SIGNATURETHIS AREA 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: o EHS: Account No. fY-7 T 0 0 Q S Revised DCHD(07/99) Invoice No. d ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account M 989900025 Tax PIN/EH#: 5789-79-5851.62 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#62 Reference Name: Location/Address: Old March Road-2700 Proposed Facility: Residence Property Size: see map Date Evaluated: Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope% HORIZON I DEPTH 10 Texture group Consistence Structure Mineralogy HORIZON II DEPTH AA-� Texture group Consistence Structure « 4 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 c/ SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: y 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 oist 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)