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283 Pepperstone Dr Lot 22 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • P.O.Bog 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002612 Tax PIN/EH#: 5820-75-9199 `Billed To: Jeff Jones Subdivision Info: Pepperstone Lot#22 Reference Name: Location/Address: Pepperstone Drive-27028 Proposed Facility: Residence Property Size: see map _ ATC Number: 3371 **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_Z #Bedrooms_ `s #Baths �1�5 Dishwasher:J?!r Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing:,0"' 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 Size10,06 GAL. Pump Tank/OOL GAL. Trench Widths Rock Depth &2_fLinear Ft.-,OC) Other: Required Site Modificati�r itions: IMPROVEN RATION PERMIT LAYOUT- APPROVED EFFL E T FILTER RISER(S)IF 6"BELOW FINISHE DE. *;**NOTICE: Contact a representative of the Davie Co H alth Department for final inspection of this system be e 1 0 ,4 . o 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of inst I ti n. Telephone#is(336)751-8760.**** 6A 1 00 41h Environmental Health Specialist's Signature: �`� Dater DCHD 05/99(Revised) y DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990002612 Tax PIN/EH#: 5820-75-9199 Billed To: Jeff Jones Subdivision Info: Pepperstone Lot#22 Reference Name: Location/Address: Pepperstone Drive-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3371 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 CON�S/TRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature:_�YAl Q Date: �f CERTIFICATE OF COMPLETIOlJ�j **NOTE** The issuance of this Certificate of Completion shall indicate the cyst es 'bed on Improvement/Operation Permit has been installed in compliance with Article I 1 of G.S.Chapter 13 1 .1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY be taken as a guarant system will function satisfactorily.for any given period of time. Q Septic System Installed By: 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 IMPROVEMENT/OPERATION PERMIT Account #: 990002612 Tax PIN/EH#: 5820-75-9199 Billed To: Jeff Jones Subdivision Info: Pepperstone Lot#22 Reference Name: Location/Address: Pepperstone Drive-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3371 **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. i Residential Specification: Building Type #People Z — #Bedrooms #Baths 11�3— Dishwasher:JZr Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing:;T*' Basement/No Plumbing: Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: Lot Size Type Water Supply _ Design Wastewater Flow(GPD)� Site: New oo' Repair 0 System Specifications: Tank SizeIA0b GAL. Pump Tank A0D GAL. Trench Width`?&�'Rock Depth 42 "Linear Ft.,9W Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFL E T FILTER. RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie CoAtVtalth 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 inst 1 ti n. Telephone#is(336)751-8760.**** t 'pT - ��a h 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 #: 990002612 Tax PIN/EH#: 5820-75-9199 Billed To: Jeff Jones Subdivision Info: Pepperstone Lot#22 Reference Name: Location/Address: Pepperstone Drive-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3371 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: 2 / Date: :V-h a 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. Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) ECS APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT& Davie County Health Department FEB ] Envirronmenia/Hea/th Section 2003 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 DANM �y (336)751-8760 �ECp�N�,EA1Ty ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for f �instructions. 1. Name to be Billed fe�.f /��Tol ie3 I Contact Person Jeff" V);Ie; Mailing Address fy-�7r'�T7�'� I$y C;1~00d Dr Home Phone 3$b—c7J77�Gy/L� City/State/ZIP Z7OV Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/state/zip 3. Application For: el, Site Evaluation JOO'Improvement Permit/ATC ❑ Both 4. system to service: R House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms �-f # Bathrooms . l/Dishwasher ❑ Garbage Disposal [Washing Machine ['Basement/Plumbing ❑ 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) 7. Type of water supply: Q'County/City, ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes VNo If yes,what type? ***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: S ee LP WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: # 5820-071-- ql qq �O/ IV ro P w1,,r E T PI �ri��t Property Address: Road Name Re 4�s',J/mG pf' ,5 h eHj 01 City/Zip If in a Subdivision provide information,as follows: Name: pr°pjoeliIme Section: Block: Lot: x Date Property Flagged: Z1 1 "C"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 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 suitability. DATE 211117-003 SIGNATURE 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: Account No. Revised DCHD(07/99) /cam �"�� Invoice No. Z _L1- Nr21'41'03" e �4 23' MOCKSVILLE, N. C. J 27028 3s. L— L2 N 34.07126" W 40 69' TELEPHONE: 704/634-2181 l Z 28o•op� s4'ooh BEING TAX LOT 99 / TAX MAP F-3 e ,I�oi RECORDED IN DEED BOOK 142 PAGE 636 ' � 'a CLARKSVILLE TOWNSHIP I! U DAVIE COUNTY, N.C. 103)S0, Ic 3 N 88.0,9'05" E U n v P9 0 CV 010 91 20 tr BURLEY EnwTN wrvEp ' --� 183.50' / TAX LOT f 41 MAP !u-♦ 2• 55� DEED BOOK 084 PAGE 740 ' 73-0 W N 88.38'38° Wj ' S 79,47'p7s 232.5b , SURVEYED NOVEMBER 2.1994 BY.,KENNETH L. FOSTER R.L.S. 2552 $OWN RUMMA�F ' t + 74 MAP G-3 VOK 047 PAGE 20d GPTON-FOSTER ASSOCIATES, P.A.' ENGINEERS—PLANNERS—SURVEYORS % ' . GENERAL NOT S: 2200 SILAS CREEK PKWY. LOS I a LOTS SERVED BY: DAVIE COUNTY WATER SYSTEM. SUITE 2B • • PRIVATE INDIVIDUAL SEPTIC SYSTEMS. WINSTON—SALEM, N.C. 27103 0 NO DRIVEWAYS SHALL Be LOCATED WITHIN 30 FEET TELEPHONE: 910-•723-2459 OF A STREET RIGHT OP WAY INTERSECTION. 0 ZONED R-A v S 2675 LINEAR FEET OP NEW STREETS. + 4 ') • MAP�. 14t rTpPs � it i ! I I� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME DATE EVALUATED —s— ADDRESS PROPERTY SIZE �/9C PROPOSED FACIILTY lo'b'e LOCATION OF SITE 44A)9'�-r Water Supply: On-Site Well Community Public 41-11 Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position -� Slope Z HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH r r Texture group Consistence Structure S /� 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 /77 1 � SITE CLASSIFICATION: PT EVALUATED BY: C� 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