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256 Old March Rd Lot 61 { _ / . DAME COUNTY HEALTH DEPARTMENT . Environmental Health Section P.O.Boa 848/210 Hospital Street Moclksville,NC 27028 (336)751-8760 V V Account M 989900025 Tax PIN/EH M 5789-79-5851.61 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#61 Reference Name: Location/Address: Old March Road-27006 Proposed Facility Residence Property Size: see map ATC Number: 3984 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: ��� Date: 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 guarantee that the system will function satisfactorily for any given period of time. 1/©y t i � y� Septic System Installed By: 1,4 11ol/ Environmental Health Specialist's Signature: -4 Date: M DCHD 05/99Revised ( ) �,��ar`I t,l topV rnA- 4a r:ak� & �l, ,I .ce._. • DAVIE COUNTY HEALTH DEPARTMENT 452!� CCD Environmental Health Section ' P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 - —0 (336)751-8760 / IMPROVEMENT/OPERATION PERMIT Account M 989900025 Tax PIN/EH M 5789-79-5851.61 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#61 Reference Name: Location/Address: Old March Road-27006 Proposed Facility Residence Property Size: see map ATC Number: 3984 **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 ZV #People #Bedrooms #Baths . Dishwasher:1210" 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) �6� Site: New Repair❑ System Specifications: Tank Size �GAL. Pump Tank GAL. Trench Width c�� Rock Depth // Linear Ft.AAP As stated In 15A NCAC 18A.1969(5 /VA Other: ftcq, stems-may atr Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISERS) IF 6 K 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.**** /�v P R Environmental Health Specialist's Signature: G%�L � Date:! DCHD 05/99(Revised) 1 y 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 M 5789-79-5851.61 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#61 Reference Name: Location/Address: Old March Road-27006 Proposed Facility Residence Property Size: see map ATC Number: 3984 **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: e Garbage Disposal: ❑ Washing Machine: 0" Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift ##Seeaats Industrial Waste: ❑ Type Water Supply L'lJ Design Wastewater Flow(GPD) y tO Site: New Repair❑ ��tioris: Tank Size GAL. Pump Tank GAL. Trench Width c�`�Rock Depth Linear Ft Z d Other: ryditions: PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISERS)IF 6"BELOW •-Contact a representative of the Davie County Health Department for final inspection of this 00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** 1 Date: APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT& ((a Davie County Health Department v �' Enwroameata/Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 MAY Jr 2002 + (336)751-8760 • ENVI ____ ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS AlI) TQ Qwl. INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instruct-Lo 1. Name to be Billed ,/fC/e� 446-0,0d, t/ OXJST/ Ger_ Contact Person ��1 fle Mailing Address vZ ,� aJIAJ(f- 11A,/6�L",v Home Phone J 7 _ City/State/ZIP Ill-WIGs Business Phone -)-A 7 2. Name on Permit/ATC if Different than Above Mailing Address City/State/ iR .9/90 3. Application For: X Site Evaluation Improvement Permit/ATC Il Both 4. System to service: 1�-House ❑ Mobile Home ❑ Business ❑ Industry U Other 5. If Residence: # People # Bedrooms 7 # Bathrooms D 4..- Ll ,iLI Dishwasher LI Garbage Disposal LI Washing Machine L1 Basement/Plumbing LI Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People 6 Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of'water supply: County/City ❑ Well I-I Community Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Cl No If yes,what type? ***IMPORTANT***CLIENTS MUST CObiPLETETHE REQUIRED PROPERTY INFORMATION REQU 'STED BELOW. Either a PLAT or SITE PLAN MUST BESUBb1ITTED by the dicnt with THIS APPLICATION. �� " 1 ��c�fj /S�t Property Dimensions: J% TO .r1C/l.� �D)"�_ WRITE DIRECI'IONS(from Mocl6ville)to PROPlat•1.Y: Tax Office PIN: # 5-7 0 `J7 5)&l l Property Address: Road Name OGe) MA"ZCW 49 /�loc/c5✓Iu� .9o{l cc 4'A'v a/ City/zip 40VAitJC' . ..7006 L6A,— e u If in a Subdivision provide information,as follows: Tri /YIAi2CN GG/onn:5 OA)2r Name: 44r4 P&I-1 6t bOOS P144-5 t' 3 Section: 'r'IA Block:N�►� Lot: C0� Date Property Flagged: 4)c /z O/-- 11V4 6 This is to certify that the information provided is correct to the best of my knowledge. 1 understand that any perinit(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,uarlerstmhd that I auh responsible for all charges incurred ftoln this application. 1,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 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: EHS: Account No. Revised DCIiD(07/99) Invoice No. ��a DAVIE COUNTY HEALTH DEPARTMENT �' •• Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account M 989900025 Tax PIN/EH M 5789-79-5851.61 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#61 Reference Name: Location/Address: Old March Road-27006 Proposed Facility: Residence Property Size: see map Date Evaluated: !/S Water Supply: On-Site Well Community Publicy Evaluation By: Auger Boring Pit Il Cut i FACTORS 1 2 3 4 5 6 7 Landscape position L L Slope% HORIZON I DEPTH Texture groupSCS Consistence Structure Mineralogy HORIZON II DEPTH Texture groupC 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: / 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 Mineralouv 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(s:)itable),PS(provisionally suitable),U(unsuitable) LTAR-Long-term a,ceptance rate-gal/day/ft2 DCHD 05/99(Revised)