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266 Old March Rd Lot 60 v r 1 Permittee'`—"-- " D�VIE COUNTY HEALTH DEPARTMENT Name: u� 5 '�� r I�Fnvironmental Health Section PROPERTY INFORMATION / //1 P.O.Box 848 Directions to property:/ J /•-` (� Mocksville,NC 27028 Subdivision Name: ��/1 G r r L� u.�r,rr) } �� �' C�ICf Phone#:336-751-8760 U;?1 f 1'e, t Section: Lot: } AUTHORIZATION FOR )�� (� Uh r` SYSTEM CONSTRUCTION WASTEWATER Tax Office PIN:#57'8q - 5 35" AUTHORIZATION NO: 003002 A Rad N��f�� r"1'� 1' G`�� �d zip. -7i�,0 6 **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits.This Fonn/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Pen-nits. (In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) cif ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION /'1? 7` 1/; IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION:BUILDING TYPE r #BEDROOMS -5—#BATHS OCCUPANTS j GARBAGE DISPOSAL:Yes or No COMMERCIAL S(PpECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE':Yes/or No LOT SIZE O TYPE WATER SUPPLY Co . DESIGN WASTEWATER FLOW(GPD) ko NEW SITE REPAIR SITE V � aso � add SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK&/+GAL. TRENCH WIDTH 3 4 ROCK DEPTH LINEAR l�Pd 317 �, a el;-^ U OTHER ,:�tEQUIRED SITE MODIFICATIONS/CONDITIONS: v� IMPROVEMENT PERMIT LAYOUT � .! CO"L -'�.✓yam,s18;1 � stated in 15A NCAC 1&x109S J�r C 1 GSL 4 accepted Systerns may al o b use U e d -[10,0 � NQ�. f4cl�a�hP� , pn e �jPe��do Al H 11A P, r UseQL . ly s i v lu PP 6 P5 ck !_ I ,� I e x, sy.'ns 14.) ILA FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: i AUTHORIZATION NO. OPERATION PERMIT BY: DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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. DCHD OV02(Revised) (1 .,. S _.. .-;._ v n... . -1'_r t. P� ,- t• -„ ..., r .e ! • P 'T.-s a y.,. a -_ . ...-. ... � .- .a `�.� �.'-. Permittees s/A DAVIE COUNTY HEALTH DEPARTMENT Name: ..Environmental Health Section PROPERTY INFORMATION P.O. Box 848 Directions to property: Mocksville,NC 27028 Subdivision Name: hN G 7` r t. c r e7l pp tt Phone#: 336-751-8760 Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:#' 7� SY •1STEM CONSTRUCTION (IG (, -( ."� 0 AUTHORIZATION NO: p Q 3 A Road Name: Zip: �L'n **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits.This Form/Authorization Number should be presented to the bavie County Building Inspections Office when applying for Building Permits. (In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) F Jf***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS -5—#BATHS OCCUPANTS J GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE 0- TYPE WATER SUPPLY cc) . DESIGN WASTEWATER FLOW(GPD) v" NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE I GAL. PUMP TANK -IAGAL. TRENCH WIDTH 4 ROCK DEPTH� LIINEAR,� � , a5 kedUr't.G„ OTHER !!U • � EQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT CJ Ctlt�Hb�• ori E b--GfIdo'�"l � �J 11 f j��r��� J►� . ' I� �-- (,, ii t� (�n is. c �u. SL, 51 Yw Al ^( 416 � J J� — a4Ltj 1< . FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: AUTHORIZATION NO. OPERATION PERMIT BY: DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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. DCHD 02/02(Revised) JUN CJ iv VV.JGd L.li.ir♦ ounty Health Department _ 4 n lunental Health Section _ P.O.Box 8-48 JAN 2S 2010 210 Hospital Slrcet - CO U 'C Couricr#:09-40-06 EIlVIRONMEMAIHEALM Mocksvillc, NC 27028 DAVIE COTI Y Phona(3,W rac(3M)753-1GSO ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection Name: bide- At>dca-5o&) aQ-k�3'i4 Phone Number 4�(p -9p7�$ 74 (Home) Mailing Address: 2 Z-5 W iyye A) "0 F- 33 L '7$ • 0109 i/ (Work) t9C.�5 4, 1�S a Z-t D L0 Detailed Directions To Site: IF-Q TZL- �Gd Property Address: 4 It V O A A raA%: V.*,A-L' d 0A iJ d4- Please Fill In The Following information About The EXISTING Facility: Name System Installed Under. ►Ck- tt ad EA SDy QinSt: Si)e- Type Of Facility: S P IL. Date System Installed(Month/Date/Year): Number Of Bedrooms:,____,3_Number Of People: 3 Is The Facility Currently Vacant?& No If Yes,For How Long? Any Known Problems? Yes No If Yes,Explain: Please Fill In The Following Information About The NEN Facility: Type Of Facility: s D Number Of Bedrooms: Number of People! Requested By: Date Requested: I- ZSdc (Signature) For Environmental Health Office Use Only Approved V Disapproved ��Comments: e-ire as oe Environmental Health Specialist Date: /—A6, *The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee , (extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order #i Amount:$ 0 Date: Paid By: ,�1, �1 Received By: Account ; I�QtJ�Z Invoice n: 73 `-• DAVIE COUNTY HEALTH DEPARTMENT � s Environmental Health Section �w 0Y P.O.Boa 848/210 Hospital Street �*1I Mocksville,NC 27028 (336)751-8760 o?&6 Account #: 989900025 Tax PIN/EH#: 5789-79-5851.60 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#60 Reference Name: Location/Address: Old March Road-27006 ATC Number: 4164 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 CIS VALID FOR A PERIOD OF IVE Environmental Health Specialist's Signature: Date: 1i J i36edroolyls 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. dw/ 10 1- Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) / f DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900025 Tax PIN/EH M 5789-79-5851.60 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#60 Reference Name: Location/Address: Old March Road-27006 Proposed Facility Residence Property Size: see map ATC Number: 4164 **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 1 l 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. I Residential Specification: Building Type #People #Bedrooms kY- #Bath$ Dishwasher: Garbage Disposal Washing Machine:e Basement w/Plumbing: 0 Basement/No Plumbing:0 Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste:0 Lot Size Type Water Supply Z1V Design Wastewater Flow(GPD)`; — Site: New Repair El System Specifications: Tank Size GAL. Pump Tank GAL. Trench Widtt[�6`'Rock Depth//Linear Ft,,-,'OP Other: AS StOtto aceeptecl SMOMS MAY also ba uaa Required Site Modifications/Conditions: INIPROVEMENT/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 1:0 in.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) l L APPUCATION FOR SITE EVALUATION/IMPROVEMENT PERMIT& 0 Davie County Health Department (� Eavlroameata/Health Section L� P.O. Box 848/210 Hospital Street Mocksville, NC 27028 �1AY S 2002 + (336)751-8760 ENVI ***IMPORTANT*** THIS APPLICATION CANNOT .BE PROCESSED UNLESS AL Z�TQGiCTfI INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instru�ctio 1. Name to be Billed ACV' H.( f'100 A) //(1*4!S% �..L,o e_ Contact Person /)1': ik' Mailing Address i, S L(1/,IJ G 11A,1f_�=�L.,IJ Home Phone %cam- 7 City/State/ZIP 14&x 16.8 //c t.=_ �l•(!. 7a�� Business Phone %1 - 7-A 7 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: Site Evaluation ❑ Improvement Permit/ATC Il Both 4. System to Service: X(House ❑ Mobile Home ❑ Business ❑ Industry U Other 1 5. If Residence: # People # Bedrooms -7) _ it Bathrooms 1.1 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: # Seats Estimated Water Usage (gallons per day) • t 7. Type of water supply: County/City U Well 1-1 Community Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes U No If yes,what type? ***IhfPORTANT***CLIENTS MUST COMPLE'TETHE REQUIRED PROPERTY INFORMATION REQU ' 'TLD BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. (G171a _ �'—/� N/SJl Property Dimensions: �% TO .�IC/1t� Cvr-�_ WRITE DIRECTIONS(from Nloclssville)to PROPI,"RT •: y Tax Office PIN: # 5 7 `�7 �� �) ��o Property Address: Road Name OG/� 1;1'q2cyV � M6(xSV/CXz /-0 /7�J'dfloV Cc '-Ako Z) City/Zip 404,-7,UCr $ .2700( LF,cr• e)A) at.��3 � ,�i� xen If in a Subdivision provide information,as follows: TO O.y 2r Name: r4y2c/-I 6tbc s Section: �� Block: ►'9 Lot: L.o Date Property Flagged: 1V15;E7/L O V 6 '� This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter arc 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. 1,also,rnnlerstand that I aur responsible fur all charges incurred fruln dais 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 to — O SIGNATURETHIS AREA AREA MAYBE 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. goo S Revised DCHD(07/99) L I�v / ') Invoice No. �i/ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ~ Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account M 989900025 Tax PIN/EH M 5789-79-5851.60 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Lot#60 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 FACTORS W142 3 4 5 6 7 Landsca a osition dllSlo % HORIZON I DEPTHTexture rou 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 n SITE CLASSIFICATION: / EVALUATION BY: L LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: ell-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)