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234 Pepperstone Dr Lot 18, 19 A ,t.s 7�!"`.y YJ+H `�� '+'i'f w�Y'��-9i."t 'YKy'Y-^,v l"`'✓ Aa...f't - .a.' �7: t -'' 1, .��/O s i 7RIZATION NO. 0 7 5 3 DAVIE;COUNTY HEALTH DEPARTMENT gr 97 Environmental Health Section PROPERTY INFORMATION P 's P.O.Boz 848 Namey�"` ►*� MocksYille;NC 27028 Subdivision Name: aq 'FL Z�T Phone#:704-634-8760, , Directions to property: Section: Lot: AUTHORIZATION FORp WASTEWATER ' Tax Office PIN:# ~~~=�- SYSTEM CONSTRUCTION - Road Name: Zip: 01 **NOTE**This Authorization for Wastewater System Construction-MUST BE ISSUED by the Davie.County Environmental Health Section prior to issuance of any Building Pemuts.This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits.: ' (In compliance with Article-11 of G.S.Chapter,I30A;Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION 49 �/ ' �'' IS VALID FOR A PERIOD OF FIVE YEARS. �E�lI4 IR6WEWrAi:7TE&tH SPECIALIST bAWVSUff r A,,.Y t•i Jai '-v •1'{4 J r"4/wr �. �f. (.�C u, w:, �J' e�, J .:+ .. 7 - 3,..-t ht '4:g �J't`�O"•v � - DAVIE COUNTY HEALTH DEPARTMENT " �' " 9- 177 IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION A PerrWi6's Names a, �- '� ~, Subdivision Name: Directions to property: Section: Lot: IMPROVEMENT OD PERMIT Tax Office PIN:# E _ �/ Road Name: i f /rte .Zip: **NOTE**This Improvement Permit DOES NOT authorize the construction or installation 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) ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER "BIRO rNMENTAL HE,6LTH SPECIALIST DATE SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION:BUILDING TYPE_,��/ #BEDROOMS #BATHS�_#OCCUPANTS GARBAGE DISPOSAL:Yes or No COMMERCIAL/SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLEISHIFr #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZES" TYPE WATER SUPPLY � DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE-&D( GAL. PUMP TANK GAL. TRENCH WIDTH _ ROCK DEPTH LINEAR FT O�) OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS IMPROVEMENT PERMIT LAYOUT "CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(704)6348760. OPERATION PERMIT \ t014l T-A y-e/ SYSTEM INSTALLED BY: U V 2v rJ T4. -TA J 4 MTC L-f> 0� S 7 AUTHORIZATION NO. S73 OPERATION PERMIT BY: DATE: (.O "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 05/96(Revised) APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERN Davie County Health Department $ 0 P Environmental Health Section fAAR 2 6 # P.O. Box 848 197 Mocksville,NC 27028 } (704) 634-8760 i ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed �.`F – d -6F— Contact Person U;l'l9 ! Mailing AddressI q� � 41�1�1 �f Home Phone �l City/State/ZipkBusiness Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: 14IFSite Evaluation improvement Permit&ATC [ ]Both 4. System to Serve: [VfHouse [ ]Mobile Home [ ]Business [ ]Industry [ ]Other 5. If Residence: #People #Bedrooms :3 #Bathrooms VOishwasher[ ]Garbage Disposal [,.}'Washing Machine [ ]Basement/Plumbing [ ]Basement/No Plumbing 6. If Business/Other:Specify type #People #Sinks #Commodes #Showers #Urinals #Water Coolers ' If Foodservice:#Seats Estimated Water Usage(gallons per day) ' 7. Type of water supply: [i'rCounty/City [ ]Well [ ]Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes [k-J No If yes,what type? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED:***IMPORTANT***ACOF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: Z16-1 �' r�(� WRITE DIRECTIONS(from ocksville)TO 'PROPERTY: Tax Office PIN: # - =- -60,L-/ _ n�O / o Property Address: Road Name x7171�r CY ,K l'CA f "T'o dQh�J D k -4f City/Zipy?72/) A.';4 S7`tr"9`►-1 ��j ,std a� ��d «/ If in Subdivision provide information,as follows: Name: -C e6-S VWe- Section: 1 Lot#• 3 �'1 P 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 Representa 've of he Dade County Health Department to enter upon above described property located in Davie County and owned by L.11/6 u e- !`n o conduct all testing procedu as necessary to determine the site suitability. DATE E Revised DCHD(06-96) THIS AREA MAY $E USED FOR DRAWING YOUR SITE PLAN: i i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAMEDATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY —� Qh Al- 'e LOCATION OF SITE Water Supply: On-Site Well Community Public- Evaluation ublic_Evaluation By: Auger Boring Pit ��_ Cut FACTORS 1 2 3 4 Landscape position Slope Z 102 HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture groupG 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: EVALUATED 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 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(01-901 - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation l NAME ,/�-��/p DATE EVALUATED ADDRESS PROPERTY SIZE f 7�¢Cr PROPOSED FACIILTY ,46�24:Ce LOCATION OF SITE Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 171k t' 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 RATEi SITE CLASSIFICATION: EVALUATED BY: , a / LONG-TERM ACCEPTANCE RATE: 7 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 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(01-901