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153 George Jones Rd (2)Account #: 990002687 Billed To: Daniel Perrell Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5758-89-1006DP Subdivision Info: Location/Address: George Jones Road -27028 Property Size: 1 acre ATC Number: 3486 **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: ❑ Commercial Specification: Facility Type Washing Machine: Basement w/Plumbing;,1"� Basement/No Plumbing: ❑ #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 14& Type Water Supply ��_ Design Wastewater Flow (GPD) c��� Site: New ❑ Repair ❑ System Specifications: Tank Size/ GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width �(� Rock Depth 42 Linear Ft Z61 IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) 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: AAI)lDate: 16`/U 61 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 #: 990002687 Tax PIN/EH #: 5758-89-1006DP Billed To: Daniel Perrell Subdivision Info: Reference Name: Location/Address: George Jones Road -27028 Proposed Facility: Residence Property Size: 1 acre ATC Number: 3486 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: 1 / Date: Zr l nl 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 O AY be taken as a guarantee that the system will function satisfactorily for any given period of time. 01e.- Septic 1.. Septic System Installed By: Environmental Health Specialist's Signature: -kM. Date: DCHD 05/99 (Revised) Fa f�J- It 2 2003 EvI ;ECTAL NA TH IN FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed p J� / Contact Person yQ�� Mailing Address S Home Phone q City/State/ZIP MocAT, lz 1/10- 7)G1 26 a!j:: Business Phone 2. 'Name on Permit/ATC if Different than Above :5ce, :M P, Mailing Address 3. Application For: iSite Evaluation City/State/Zip ❑ Improvement Permit/ATC ❑ Both 4. System to Service: .YHouse ❑ Mobile Home ❑ Business S. I£ Residence (dishwasher # People I_ # Bedrooms 3 ❑ Garbage Disposal IV/Washing Machine 6. If Business/Industry/Other # Commodes Specify type # Showers ❑ Industry ❑ Other Basement/Plumbing # Urinals # Bathrooms ❑ Basement/No Plumbing # People # Sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: 1K' County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes a No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORIIMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBM17TED by the client with TI -IIS APPLICATION. Property Dimensions: Tax Office PIN: # / , t(:N p n b DP Property Address: Road Name z C/ V City/zip2iock 5 y;1/6 /7), G - If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: Y 42 V 64t Lz 5 t -"o C©F1Jet,47—Cs-- /dol t- CLai^72aizek 179re, o 2/1or,es R1 o;,.> 4-��oI Pi,+Yen 1? 1'g 4 - Date Property Flagged: 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 ant 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 �? e, to conduct all testing procedures as necessary to determine the site suitability. DATE 7- ;� 0 3 SIGNATURE .Y in� ��,�i� Vnn 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). Revised DCHD (07/99)— �,l l t Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. 014- QP Invoice No. -3 -S� / 0 tj ✓ ' 63 S" (1 3.40A) FACTORS 1 2 3 4 5 6 7 Landscape position ' DAVIE COUNTY HEALTH DEPARTMENT Sloe % Environmental Health Section HORIZON I DEPTH �p � •� Soil/Site Evaluation APPLICANT INFORMATION Consistence PROPERTY INFORMATION Account #: 990002687 Tax PIN/EH #: 5758-89-1006.DP Billed To: Daniel Perrell Subdivision Info: HORIZON II DEPTH Reference Name: Location/Address: George Jones Road -27028 Proposed Facility: Residence Property Size: 1 acre Date Evaluated: Water Supply: On -Site Well `. Community Public Evaluation By: Auger Boring IPit Lor Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Sloe % HORIZON I DEPTH �p � •� Texture grouph �' Consistence Structure Mineralogy HORIZON II DEPTH Texture group 0 - Consistence Consistence _0 Structure S /4- :5&."l 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: lel1� 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) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■e■■■e■■■eee■■■■eee■■e■■■■e■■■■ ■e■■e■■■■■eee■■■■■■■■■e■■■■■■■■■ ■e■ecce■■■■■■■e■■■■■■■■■■■■■■e■■■■■■■■■■■■e■■eeeee■■■■■■■ecce■■ee■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■e■■eee■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■eeee■■e■■■ee■eee■■■■e■■■■■■■■■ ■eee■■■■■■e■e■■■■■■■■■e■■■e■■■■■ ■■/■■■■■■■■e■■■e■e■ee■■e■ee■■■■■■■■■■■■e■■■e■■■e■e■■■■■■e■■■■eeee■ ■■■eee■e■■■■■■ee■e■■■■e■■■■■ee■■ ■■■■■■■■e■■ee■e■■■■e■■ee■eeeee■■ ■■■e■■e■r�i�e■■■■■■e■■■ee■■e■■■■■eee■■■■■■■■■e■ee■e■■■e■■■e■eee■■■e■ ■e■ee■e■■■e■■■e■■eee■■■■���■■■eee■■■■■■■ee■■■■■■■■e■■■■■■■ee■■■■■■■ ■■e■e■■■■e■■■e■■e■■ecce■■e■■■......•_:cc,�e■■■��■■■■■ee■■■■e■e■■■■■■ mammoniiiiiiiMiiiiiiiiiiiiiiiiiiiii�,,iiiiiiiiiiii ■■e■ee■■■■ecce■■■■■■■■■t■■■e■■■■■e■■e■■e■u■e■■��■■■ie■■■e■■■■■■■■■■■■ ■■■■■■■■ecce■■■■■■■■■■■t■■e■■■■■■■e■■■■■ene■■e�r■en■■e■e■e■■■e■■■■■■ ■■■ee■e■■eee■■■■■■■■■■■i■■■■■■■■■■■■■e■■■■�e■■■�i■■pie■■e■■e■e■■■■■e■■ ■ee■■eee■■■■■■■■■■■■■■e■■e■■e■■■■■■■■e■e■■■■e■■ee�■ee■■■ee■e■■■ee■ ■■e■■e■■■e■e■■e■■■■■■■■■■■■■e■■e ■■■■■■■■ee■■►�■e�r■■■■■■e■eeee■e■■ ■■■■■■■■■■■■■■■e■■ee■■■■■ee■■e■■eee■■■■■■■e■■■e�■■n■e■■■■e■■■■■■■■ ■■■■e■■■■■■e■■■■■■e■■■■■■■■■s■■■■■e■■■■■■ee■ee■■►�e�■■■eee■ee■■ee■■ ■■■eee■■■e■eeee■ee■■e■■■ee■ee■ee■■ee■eee■■e■■■e■■��et►�■e■■eeeee■■ee■ ■■e■■eee■■■■■■■■■e■■■■■■■■■■■■■■■■■■■■■■■e■■■■■■■\e■1■■■e■■■e■■■e■ ■ee■e■■■■ee■■ee■■e■ecce■■■e■■■■■■■■■■■■e■ee■e■■■eet�ei�ee■ee■■■e■ee■ ee■eee■ee■■■■■■■■■■■■■■■■■■■■■■■■■■■■■e■■ee■■■■■■■i■■��■■■e■■■■■■e■■ ■■■■■■■■■e■e■■■■■■ee■e■■■e■■eee■■■■■■■■■■■e■■■■■■■u■i�■■■■■■■■■■e■■ ■■■■■■eee■■■■■eee■■■■■■e■■■e■■■■ee■■■■■■■■ee■e■■ee■■■■■■■■eee■e■■■ April 15, 2003 Daniel Y. Perrell 153 George Jones Road Mocksville, NC 27028 Re: Site Evaluation/ George Jones Road Tax Office Pin : # 5758-89-1006 DP Dear Client(s): As requested, a representative from this office visited the aforementioned site on April 14, 2003. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed ori the site, the site was found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions, please feel free to contact this office. Sincerely, X0 g a &, 4 � �A. Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/df