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304 Frank Short RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001126 Tax PIN/EH #: 5757-42-8866 Billed To: Timothy Peeler Subdivision Info: o Reference Name: Timothy Peeler Location/Address: Frank Short -27028 Proposed Facility: Residence Property Size: 12 Acres ATC Number: 2413 **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: YJ Garbage Disposal: ❑ Washing Machine: p"' 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 Repair ❑ System Specifications: Tank Sizer o GAL. Pump Tank GAL. Trench Width Rock Depth `Linear Ftk—' —40, Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISERS) 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.**** Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ' P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001126 Billed To: Timothy Peeler Reference Name: Timothy Peeler Proposed Facility: Residence ATC Number: 2413 Tax PIN/EH #: 5757-42-8866 Subdivision Info: Location/Address: Frank Short -27028 Property Size: 12 Acres 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 WASTE WAT CONSTRUCTION ISS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: - C 1'fC Date: �� oO CERTIFICATE OF CO **NOTE** The issuance of this Certificate of Completion shall indicate th sysl has been installed in compliance with Article 11 of G.S.hapt 1 Disposal Systems," but shall in NO WAY be taken as a guae�effirae given period of time. Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) N d on Improvement/Operation Permit .1900 "Sewage Treatment and n will function satisfactorily for any Date: APPUCATION FOR SITE EVALUATION/IMPROVEMENT PERMR & ATC 1 Davie County Health Department R I En vfrvnmenta/ Hen/tai Smdon O L� tl N] R B v P.O. Box 848/210 Hospital Street . Moakaville, NC 270289 2000 (336)751-13760 APR ***IMPORTANT*** THIS APPLICATION CANNOT aE PROCESSED UNLESS AL14 TH$`lij(�jy " INTOM&TION IS PROVIDED. Refer to the INFORMATION BULLETIN for"MnstkucElons. 1. Liame to b. allied / . eI t° Contact Parson /rn n"Pe -e-1 e� jr(�l is — Mailing Address 0 ��1J /I�f O hose phone 3.3tr? .~ �f�1q 8 "T Vo(y City/state/21P 1 1 1 b (-SCSJ R I 1,P_ 1% � r/. / o� l? Business Phone 3 3 & "- -,;Q ci — 90.E 2. Mama on Persit/ATC if Different than Above Mailing Address 3. Application For: A'Site Evaluation City/state/Eip / 0 Improvement Permit/ATC O'Both 4. system to service: "01156 ❑ Mobile Home ❑ Business 0 Industry O Other 5. If Residence: f People �1'- _ # Bedrooms _4 # Bathrooms W15ishwasher ❑ Garbage Disposal N-lis.hing Manhine ❑ Basement/Plumbing Ole—amant/No Plumbing 6. if Business/Industry/others speaify type + people i sinks # Commodes i showers i Urinals • Yater Coolers IS FOODSERVICE: # Seats Estimated Nater Usage (gallons per day) 7. Type of water supply: ❑ County/City ell ❑ Community 9. Do you anticipate additions or expansions of the facility this system Is Intended to serve? 0 Yes E140 If yes, what type? *"IMPORTANT**" CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: /o2/E�G• Tax Office PIN: 0 . S %S- % - Y2 - 8'? ) 4 6e Property Address: Road Name & ,a V)lSi► d�� citylzip If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from MockrAlle) to PROPERTY: (,,a I -:5oa+h 46 '-Do-a-ck moN`Rd L'44 plo J0 :I-Aw�c $110. 12- 0; Pr'1r� r4 .-( Rc jee,� Date Property Flagged: 14- If -0 ) 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 from 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 i< ^13ha !' to conduct aU testi/ng procedures as necessary to determine the site sultability. DATE ! I z igo o SIGNATURE THIS AREA MAYBE USED FOR DRAWING YOUR SITE PLANPcIudeallof the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). M Revised DCHD (07/99) Site Revisit Charge Date(s): I Client Notification Date: I EHS: Account No. Invoice No. �ys� N 50.04'26' E 358.94 t S ZI. 18'50' E 19024 1 AO° N 58. IT 53' E J �� 158.03 / 'N 74•q3'4P E Ai + 256.19 S 23.57' 20' E 113 . N 69.IB' E� (157.02 total) S 72,36,28" W 5 59 / 288.63 N 69.10' I8' E J �° • 6.01 / 15,31 1sr.?1 AP N 82' 43'10" EN 80.55' 39' W 144.52 AREA = 3.000 ACRES 25.59 /q AVCLLDES Sit 1803 R/W MP S 04. 43'45' E � N 82;43 -Ir E � je AND 41.39 2.14 \ AMP 5 78*52.533' W I+ 3 N 81'47'17- EMP S 12.51' 23' E 46.62 ID.06 /3jS/g POP S 76;591191 8.03 W / AQP AAP 58.43 \ N81.47'I7'E — $ 164.91 �� S T5.18' 04' W \ AMP 97.30 N 81* 47' Ir E 20 INCLUDES SR 180 / W 61 .RNor a1c.00towL �LIE r \ \N ar 4T Ir f `4i �. ply \y 0. \35.00 lire // ss, s Q/ ?0 va 00 �r f OP O.4 41�11) c�,� /� •P -A AREA 41fti`' INCLUDES S.R. 1603 R / W lar v BOJ. S9i 0 4 100 A, - VP T;. N 04. 02' 18' E ?70.00 N 04' 32' 19' E / S -ME ` N S" DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section Soil/Site Evaluation • APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001126 Tax PIN/EH #: 5757-42-8866 Billed To: Timothy Peeler Subdivision Info: Reference Name: Timothy Peeler Location/Address: Frank Short -27028 Proposed Facility: Residence Property Size: 12 Acres Date Evaluated: �� iv Zb Water Supply: Evaluation By: On -Site Well Community Auger Boring ✓ Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % C HORIZON I DEPTH Texture group 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 SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: j REMARKS: EVALUATION BY: ,10 / OTHER(S) PRESENT: 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) ■ ■ iii on SEEM ■E■■ MEMO NONE ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ SSSS ■■■■■■■■■■■■■■■■■■■■■ ■■■■M■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ SSSS ■■■■■■■■■■■■■■■■■■■■■ ■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■E■ OMEN HOME ■E■■ ■EM■ MEMO ■E■■ NONE ■NN■ MEMO NONE ■M■■ NEON ■■■■ ■■■■ ■M■■ NEON NONE ■■■■■■M■MM■■■ESM■■■■M■■E■■■See■See■■■■■■■■■■■■■ ■■..■■..:�■■■■..Ec■■■M■■E■■■■■ecce■■■■■ecce■■■■■ ■■MM■e■■■■■■■ME■■E■M■nE■MM■■■■ME■MEM■E■■M■■See■ ■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■E■■E■■■■■■�M■■■■■E■■E■■■■ME■■■■■ESM■■■■■■■ ■.■■■■■■■■■■■■■■■ ■■EM■■■■■■■■■M■■■ ■■■■■■■M■.EME■E.■ ■■■■■■■■.■■M■■.■■ NEEM■■ ■■■■■■ ■ ■■M■■■�■e■■■■ ■ ■■■■■■■■■■■■M■■■■ ■■■■E■E■■■■■MEME■ ■■■■■■■■■E■■■■■■■ ■M■■■■■E.■■■■E■■■ ■E■E■EEMO■■E■E■M■ ■■MMME■EME■ENM■M■ ■■EM■■■M■■■M■■■■■ ■M■■E■E■EMEN■■M■■ ■■■■■■■■■■■■■■■■■ ■MEMM■■■M■M■NN■■M ■M■■EEMMM■■■MME■■ ■M■■MEM■■■M■E■ME■ ■E■■■MME■MENE■■E■ ■MME■■■■■EMN■■■E■ ■O■E■E■E■EM■■M■E■ ■■ME■■M■■E■EM■■E■ ■■■■■■c■■■■■■■.■■ ■.■■■■■■■■■■■■■■■ ■■■■■■■E■■■■■■■■■ ■■■■■■■■■■NNN.NN■ ■■■■■■■■■■■■■■■■■ ■■■■■■■E■■■■■■■■■ ■■M...■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■.c■■■■■■■■ ■■■■MM■■■■■■■E■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ M■MM■■■■■■■■■■■■■ NN■NNN■■■■■■■■■■■ ■MME■M■■M■■ME■■M■ ■■■■■■E■ENME■■E■■ EMEM■MMEMEMEMMES■ MMERR mwMMMmM MEMNON MEMNON MEMNONZ SSSS■■ ■■■■■.■■.■■■■■■■■■■■■■■■■■■.■.■ SSSS■■ ■■....■■■■■■■■■■■■■■..■.■■■■■■■ ...................................... ....................................... ....................................... ....................................... ...■................................... ...... ............................... ....................................... ....................................... ....................................... ....................................... ....................................... ■■■■■E■■■ ■E■EMEM■■