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270 Pepperstone Dr Lot 20 DAVIE COUNTY HEALTH DEPARTMENT t Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 989900571 Tax PIN/EH#: 5820-75-5104.20 Billed To: Shuler Building Subdivision Info: Pepperston Acres Lot#20 Reference Name: Location/Address: 270 Pepperstone Drive-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3385 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,S on.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATE N TRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �• Date: 'Vl � 2 3 �roo s CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate ofC ion shall indicate the system described on Improvement/Operation Permit has been installed in complianc Lt�en Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall ' NOuarantee that the system will function satisfactorily for any given period of time. J Septic System Installed By: / ',� Environmental Health Specialist's Signature: A Arjfj Date: DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section i. P.O.Boa 848/210 Hospital Street • Mocksville,NC 27028 ��— (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 989900571 Tax PIN/EH#: 5820-75-5104.20 a Billed To: Shuler Building Subdivision Info: Pepperston Acres Lot#20 M 2 Reference Name: Location/Address: 270 Pepperstone Drive-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3385 **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 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 ( O Design Wastewater Flow(GPD) Site: New Repair❑ System Specifications: Tank Size&_GAL. Pump Tank GAL. Trench Width,5:�� "Rock Depth .14/ Linear Ft,;Ord Other: 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 1:30a3LQf]nc�tallation. Telephone#is(336)751-8760.**** Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) J E M' t, P N FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC MAA 6 20( Davie County Health Department Envinvnmentailfeaith Section .O. Box 848/210 Hospital Street ENVIROPIMENTAINFALTN Mocksville, NC 27028 DRVIE COl1idTY (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIjDED. Refer tt�o� the INFORMATION BULLETIN for instructions. 1. Name to be Billed �//y/tI' U i I ;/I5 Contact Person ��,�t cri�✓fig• Mailing Addressryay`�/u ler^1420 Home Phone Y9o7 7.v 5- City/State/ZIP /ye Business Phone d 7- 2. Name on Permit/ATC if Different than Above Mailing Address city/state/zip 3. Application For:. ❑ Site Evaluation R-!Lprovement Permit/ATC ❑ Both 4. System to service: mouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. I£ Residence: # People # Bedrooms - # Bathrooms Z Q'Sishwasher e'carbage Disposal tr Washing Machine ❑ Basement/Plumbing asement/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) 7. Type of water supply: I 2/County/City ❑ Well ❑ Community a. Do you anticipate additions or expausions of the facility this system is intended to serve? ❑Yes RI&O If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLATT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: 40", Sap 4epr0Y WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: # 57 oZ Q 7625-�d 6"el Nary 9 Z&k e-e,7 .4e ne, At, Property Address: Road Name o?'70 Pc ye.� ��, /( �d le" City/Zip Moe..2-.&,;#e A)ie. 7vzt ors on A/r to Gle,,..0 1,,P"- If ovaIf in a Subdivision provide information,as follows: Name: P'�,nwm/on c Section: Block: Lot: a0 i t 9. Date Property Flagged: 3' 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 Davi] ounty Health Department to enter upon above described property located in Davie County and owned by f4 d�u to conduct all testing procedures as necessary to determine the site suitability. ,o DATEc3�-03 SIGNATURE �lY f�`ikX THIS 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: r EHS: Account No. 2 tfl o 6:-7 Revised DCHD(07/99) . Invoice No. ter" TY HEALTH DEPARTMENT DAVIE COUNTY /ter �0 • Environmental Health Section - ' J Soil/Site Evaluation NAME /�j^ DATE EVALUATED _SP5 ADDRESS PROPERTY SIZE PROPOSED FACIILTY /—)19 z/J P LOCATION OF SITE _�(1/1�►/idts/' Water Supply: On-Site Well Community Public // Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position �. Sloe % 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 EE 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