348 Shady Knoll Ln � � DAVIE COUNTY HEALTH DEPARTMENT //�� ����
Environmental Health Section
P.O.Boz 848/210 Hospltal Street
; , Mocksvllle,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001065 Tax PIN/EH#: 571&11-3291
Biiled To: Janice Peeler Subdivision Info: �
Reference Name: Janice Peeler Location/Address: Shady Knoll Lane-27028
Proposed Facility: Residence Property Size: 3 Acres
**NOT�*'N�is�mpr vem�ent/Operarion 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 Treatraent and Disposal Systems). THIS
PERMIT LS SUBJECT TO REVOCATION IF STTE PLANS OR T�IlVTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THLS PERNIIT BEFORE INSTALLING SYSTEM.
Residential Spacification: Building Type H d J�� #People 2 #Bedrooms 3 #Baths z• �
Dishwasher: � Garbage Disposal:❑ Washing Machine:�Basement w/Plumbing: � Basement/No Plumbing. �
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: �
Lot Size ��'��s Type Water Supply IJI�GI-V Design Wastewater Flow(GPD),��D_ Site: New�Repair❑
System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width�� Rock Depth 1Z• Linear Ft.�-'a'
orher: 1 �s��j��.� c��-�c� �.�sTa�L �,ac� Qt�o.c, r��,�.
Required Site Modifications/Conditions: 1�5��-L- �� �''Sto� � �C"7� �.on.- �.J�.t- IL�t=� �p� ��0�
ua�
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6 K BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis
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.****
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DCHD OS/99(Revised)
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° ' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/l10 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990001065 Tax PIN/EH#: 5718-11-3291
Bilied To: Janice Peeler Subdivision Info:
Reference Name: Janice Peeler Location/Address: Shady Knoli Lane-27028
Proposed Facility: Residence Property Size: 3 Acres
ATC Number. 2390
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLTST 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 WASTEW CTI IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signatu e: Date: �
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate of Completion shall indicate the system described on ImprovemendOperation 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 the tem will function satisfactorily for any
given period of time. `Z�
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Septic System Installed By: � C.�1 G �"i
Environmental Health Specia]isYs Signature: Date:� �
DCHD OS/99(Revised)
n LS � L5 0 V `��,- _..—
APPLJCA�ON�OR SITE EYALUATION/IMPROVEMFM PERMfT& C!
° � Davie County Health Department � 2 7 2��1�
Environmenta/Hea/th Section
P.O. Soa 848/210 Hospital Street
Mocksnille, NC 27028 l �,�ywr :.,;>.;...
(336)751-8760 •.
***I1�'ORTANT*** THIS APPLICATION CANNOT 8E PROCESSED UNLESS ALL THE REQUIRED
INFORMATION I3 PROVIDED. Refer to the INFORMATION SULLETIN for instructions.
1. Name to be Billed ����C� 1"Ci�l,l�R Contact Peraon __�j/'(►►��
Mailinq ]►ddreas ���1(I S� ����1\�� �1/• Home Phone 33(o-'�a3J /�1'✓
�==�>�:�-w��=� �l in��'m�1-,S�4 t,�rn NC ����3 �-:��e9� n::��� 33(�-(�5�-`l�?S
2. Namo on Parmit/ATC i! Dilfareat than ]►bove
Mailinq �ddreas City/State/2ip
3. Application For: ❑ Site Enaluation ❑ Improvement Permit/ATC �Both
a. syntsm to sorvice: H House ❑ Mobile Home ❑ Business O Industry ❑ Other
s. if ttesidence: � People _�� � Bedrooms �' _ � Bathrooms a,�_
M Diahwasher ❑ Gasbage Dieposal [Y Naahing Machiae �fl Saeament/Plumbing �Hasement/No Plumbing��
6. I! 8usiaess/Industry/Othor: Spacify type � People # Sinka
� Commodea # ShoMers / Urinala � � Water Coolers
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IF FOODSERVICE: • # Sests ` EstimBted Water Usage (gallone per day)
7. Type of water supply: 0 County/City EI Well ❑ Community
e. Do you anticipate additioas or ezpansions of the facility t6is system is intended to serve? ❑Yes �No
If yes,w6at type? �
***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
_ • BELOW. Either a PLAT or SITE PLAN MUSTBESUBMI7TED by the client with THIS APPLICATION. �
Property Dimensions: 3 � � WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Taz OYtice PIN: # .57��� ��-3a R 1 ��� � GO �T 1�D b f�Y ��` ) Iv[ •"1.
Property Address: Road Name �� S�� �J�(,L �ItuE �J ` ��
City/Zip I��SIJI(,L,� oZ.���-� � .
.
If in a Su6division pravide information,as follows: '
Name: � �
Section: Block: Lot: Date Property Flagged: �'�'2�"�U�
This is to certify that the information provided is correct to t6e best of my knowledge. I understand t6at any permit(s)
issued hereafter are subject to suspension or revocation,if the site plans or intended use chaage,or if the informatioa
submitted in thjs application is falsiGed or c6anged. I,also,understand that I am responslble for all charges incurred from
thls appllcation. I,6ereby,give consent to t6e Authorized Representative of the Davie County Healt Department
to euter upon above described property located in Davie County and owned by 1�A/Yl 11,�:P
to conduct all testing procedures as necessary to determine the site suitability.
;"bATE �J'��"W SIGN �RE `
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'T�IIS AREA MAY BE USED FOR DRAWING Y S PLAN(Include all of the following: Ezisting and proposed
property lines and dimensions, structures, se , a septic locations).
Site Revisit Charge
� �;� Date(s):
p �,? , Client Notification Date:
U � EHS:
�� Account No. ���
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Revised DCHD(07/99) 5,p �0 � Invoice No. `�Ya�-
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DAVIE COUNTY HEALTIi DEPARTMENT
Environmental Health Section
' ' ' ' ' Soi]/Site EvaluaHon
APPLICANT INFORMATION ' PROPERTY INFORMATION
Account #: 990001065 Tax PIN/EH#: 5718-11-3291
Billed To: Janice Peeter Subdivision Info:
Reference Name: Janice Peeler Location/Address Shady Knoll Lane- 7028
Proposed Facility: Residence Property Size: 3 Acres Date Evaluated: �� °�
Water Supply: On-Site Well � Community Public
Evaluation By: Auger Boring `� Pit Cut �
FACTORS 1 - 2 3 4 5 6 7
Landsca e osition L L L..
Slo % 3
HORIZON I DEP'TH t9 ��P o" I
Texture rou C C C
Consistence rSSS `S.,Q
Structure C <
Mineralo � 1 �� I• (
HORIZON II DEP'TH • 2 -2 ► � �S
Texture rou C�1- �
Consistence rS
SWcture L
Mineralo l; � ' :
HORIZON III DEPTH 32�-
Texture rou
Consistence �5
Structure k
Mineralo (�� �
HORIZON IV DEPTH �
Texture rou .
Consistence
Structure
� Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON •
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE O• D•
SITE CLASSIFICATION: �� EVALUATION BY: v�T� 4�....—P
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
Mineraloev
' 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-gaUday/ft2
DCHD OS/99(Revised)
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