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130 Hepler Rd4 . Account #: 990002693 Billed To: Todd Ellis Reference Name: John Duncan Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 .0D IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5759-67-0781 Subdivision Info: Location/Address: 130 Hepler Road -27028 Property Size: 6.43 acres **NdiIss qj4nbTr4rovement/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 l 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. Residential Specification: Building Type #People _ #Bedrooms _ #Baths 3 Dishwasher:; Garbage Disposal: ❑ Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial 13iaal Waste: Lot Size Type Water Supply �ei Design Wastewater Flow (GPD) —Wd Site: Nevem Repair ❑ System Specifications: Tank Size AW GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width 7l' Rock Depth Linear Ft O / 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. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002693 Tax PIN/EH #: 5759-67-0781 Billed To: Todd Ellis Subdivision Info: Reference Name: John Duncan Location/Address: 130 Hepler Road -27028 racmty: Kesiaence ATC Number: 3433 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: 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. 12sv�,rx r z© ^ VP L - Septic System Installed By: Environmental Health, Specialist's Signature: �' / / ! Date:?� e/ DCHD 05/99 (Revised) 04/06/2009 21:19 FAX 7048719665 J TODD ELLIS Apr 04 03 11:25a davie county envhealth 336 751 9766 IN FOR FAU EVALUATION/LMPRONEMUff PERMIT d AYC Davie Cow* Health Department EAY1flWl/ll�/t�l MC13/dt Ser�hA P_O. Sex 866/210 Hospital Street Hookeville, NC 27026 (336)751-8760 a+*"TB-13 APPLICRTION CMNAW BE FJU=SS= UbUZSS ALL TAE REQUIRED IS PROVIDED. Roger to the XNwUZQ4%Ti0rt SULLET3:N for inatsactiona. .s. tae to be st-A2—► 950.41 ev- city/state/ate ,3-F1X- lPSyi VP /U l: C49 129:4 z. tram oo aesdit/Alc ar O=wmaat tban Avow owilioy Address /S/`l Old 64TAA zg�1 3. Application For: 0 Site 3valuetion Coarser rezaanIT rho oa c Man* 7dy 6/1 q city/stawaip 1201 P.2 0 TWzcrvtawat Permit/ATC ff Both tet, syerao to sdrvtes: xRouse U Mobile Home a Susinean U xndutatry O Other xf fteidenoa: i pooplo T i sedroasse a Baths 0osts _ --xDiatesasher n Ossaage disposal A Mashing tlarhiae U aaawaot/Dlambisq It Xasnownt/lro Plumbing S. If eustA6ee/I&ftstry/0th+ : Specify type a t�vO'ple a Binta I a s abowrs t urinals I Maur Cwlac* Ir FOODSERVICE: $ seats Estimated Water Ussgo /gallons you day) /r Trpa of water wapply: 0 couatr/City rkwall w coaeanity -.Ar Do you anticipate additions or etpaasiims of the faeility this rysteas is intended to serve? 13 Yes XNO If ye:, what type'. ***,rAJPORTANT'** CLIKKI I MIMMOMPIRMTHB REQUIRED PROPERTY INFORMATION REQUESTED -- W. Furber s FLAT or SITE PLATY MUST DESUdMl77CD by the chest will► THIS APPLICATION. Property Dimensions- Ad, X lo7 C�/�fy� 1 �ffiet PIN: P /4�! J 7-- j /(30I Property Add, P-11, Road waste Citymp /GItS✓ C V4 in a Subdivision provide information, as follows: WRITE DIRECTIONS(from Modavitle) to PROPERTY: 1 ter- %-- Nater: (�O il�tit.f sP jMr� 9 Q • Secties: Bloch: Lot: tt Property Fiactd: `r� This is to certify that the iniormadw provided is correct to the best of my knowledge_ 1 u1o1ersts0d, that any pertnit(s) iseamd hereafter are subject to sa mpemion or revocation. if the site plans or intended use chaoge, or if the information momitta:d in ibis application is bWfied or changed, L also, understand that Jam reiponsiblefor oil charger incurred from 11th applicalloti 1. hereby. give consent to the Authorized Representative orthe Davie County Health Department to enter upon above described property located in Davit Cwtmty and *weed by to conduct sit testing procedores as neresmary to determine the mitt suitability. r Xt5-03L---DATF, SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLANaelude all of the following: Existing and proposed C lfv-(, e7b V- 8114(e 5 5-"r -f-, C- caP Y 04/08/2003 21:19 FAX 7048719885 3 TODD ELLIS pnVeM uses and dla:easiam% stractum sef,6ack36 sad septic Iccatimts). Rtvkad DCHD (07190 t 75 i i St?4 l i1 e5 j t S66 1. 1 V .. I licyK fx-wk� 002 Site Revisit CbzFV Date(s): Cficat INedirwstfoa We: IHS - invoice No. 2a� N-014 t� M 7sx'30 y aux z t� A Yte 4o 5,e� -��- a, CoLl P Ale r ldjC1e/'e W e- ` 114 )7 N (1158) n M h (24.06A) 2215 g 1257 3 4E a � � § � 3�3 X31 lun n'� t I, (6-�4UA)a 'ifxr333 N (324) 1268 1%30 K. 700 ,„ �J3.35A) 2027 176 6501 77 to 2 3 .07A) Sas (6.50A) N 6400 1397 X388 ; 710 91 9086 w a63 Aas a1 121 "IVI M i v r � i i i i i 126 c 1 6 0 ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002693 Tax PIN/EH #: 5759-67-0781 Billed To: Todd Ellis Subdivision Info: Reference Name: Location/Address: 130 Hepler.Road-27028 Proposed Facility: Residence Property Size: 6.43 acres Date Evaluated:vl Water Supply: On -Site Well L,""Community Public Evaluation By: Auger Boring { ✓ Pit j ? Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH Texture groupC Consistence Structure Mineralogy HORIZON II DEPTH Texture groupG Consistence Structure iL 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: REMARKS: EVALUATION BY: 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)