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122 Pepperstone Dr Lot 3 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Bog 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001671 Tax PIN/EH#: 5820-55-4280 Billed To: Jeff Wilson Subdivision Info: Pepperston Acres Lot#3 Reference Name: Location/Address: Pepperstone Drive-27028 Proposed Facility: Residence Property Size: see map 77 **NOTE-**'Ilii bgmproveeme nt/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 1 #Bedrooms -? #Baths Dishwasher:F<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_ Design Wastewater Flow(GPD) �� Site: Ne v Repair❑ System Specifications: Tank Siz%GAL. Pump Tank GAL. Trench Width_ Rock Depth /C� Linear Ft,� Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISERS)IF 6 u 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: Date: � — DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT o� Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990001671 Tax PIN/EH#: 5820-55-4280 Billed To: Jeff Wilson Subdivision Info: Pepperston Acres Lot#3 Reference Name: Location/Address: Pepperstone Drive-27028 Proposed Facility: Residence Property Size: see map ATC Number: 2770 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 Fonm/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: (1j Date: 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.Chapt ,Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY be taken as a guarant t the system will function satisfactorily for any given period of time. yj Septic System Installed By: w ry Environmental Health Specialist's Signature: Date: �''��(�"�/ ✓ DCHD 05/99(Revised) ° APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Davie County Health Department U u l5 Environmental Health Section P.O. Bos 848/210 Hospital Street W 3 0 M Mocksville, NC 27028 (336)751-8760 ENVIRONMENTAL HEALTH DWIE ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed N PS�� S n V-1 ^ Contact Person Mailing Addreas - -�3.3— �r`7�C�fl� \ )v Home Phone City/State/ZIP MC-- -)r�i�f 1, P M.1G o7-I�:�Busineas Phone 17-y1 r-7)0 2. Name on Permit/ATC if Different than Above Mailing Address City/state/Zip 3. Application For: ❑ Site Evaluation C Improvement Permit/ATC ❑ Both a. System to Service: L�Ho se ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People E # Bedrooms 3_ # Bathrooms dishwasher ❑ Garbage Disposal �"ashing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes I Showers # Urinals # Water Coolers IF FOODSERVICE: )# Seats � Estimated Water Usage (gallons per day) / 7. Type of water supply: 17 County/City ❑ Well ❑ Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes "0 If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: # 5 a -_ 5 - LA 0?8 a iy° I � � d n D R n/Uti- Property Address: Road Name V t _ U\ Pep�crt S f►�-e City/Zip }--3' O f'-+'e-e ✓' c If in a Subdivision provide information,as follows: Name: Q 1 n t A4-S Section: Block: Lot: . Date Property Flagged: / Zo- 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 `� � 1 O SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all o following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: EHS• Account No. Revised DCHD(07/99) Invoice No. 1 g ...., .....,.. +w.e..i. .,,,,i_.._... .-... A.:".�i� :•':e,•,. I•wt•., � .`<•iy iS;*,rwa aLM1ti v.- 'rR - . R, Davie C••ount---"yIIL Health Department ENVIRONMENTAL HEALTH SECTION P.O. Box 665 Mocksville, N.C.,.27028_ AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION (Issued in compliance with Article 11 of G."S. Chapter 130A,- Wastewater Systems) ***This Authorization For Wastewater System Construction must be issued by the Davie County Environmental Health Section prig o issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits.*** AUTHORIZATION NUMBER �< NAME , /l�//'i/`,f a� 6rj�/ DATE _ _�O��s'��s N2 7 NAME ON IMPROVE?EM(T PERMIT (If different an above) f .. SITE LOCATION 9 S4f1 I COMMENTS/CONDITIONS ON AUTHORIZATION TDWASTEWATER SYSTEM **+MO/TICE*** THIS AUTHORIZATION MSYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. ENVIRONMENTAL HEALTH SPECIALIST T DATE DCHD 10/95 wrl.• .5.5`.a.a...i',- ,`f.v - ,:-;-.J ..-,.F _. .,;._.. .�1..�.ix ..� l rt... f r i"-"_ c L .. t _" i V a t . ..... __ " 1 DAVIE C00 HEALTH DEPARTMENT IMPROVEMENT PERMIT and OPERATION PERMIT IMPROVEMENT PERMIT **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) NAME Z�0%�01 6i_'!/S PROPERTY ADDRESS boon-A E 1—�. • DATE �— LOCATION SUBDIVISION NAME FLMgi�rigfp11 e. H Cr e.S LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE Nei/f l # BEDROOMS ?_ # BATHS �2 0 OCCUPANTS GARBAGE DISPOSAL: Yes. COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE f1(' TYPE WATER SUPPLY _ DESIGN WASTEWATER FLOW (GPD) FEW SITE/,--' REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PIMP TANK GAL. TRENCH WIDTH 3l„ ROCK DEPTH IJ LINEAR FT. OTHER __., REQUIRED SITE MODIFICATIONS/CONDITIONS: *HTHIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. " IMPROVEMENT PERMIT BY A,// **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M. OR 1:WI:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760. OPERATION PERMIT SYSTEM INSTALLED BY rr 1 AUTHORIZATION NO. OPERATION PERMIT BY DATE }*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 FUNrCTION SATISFACTOPILY FOR ANY GIVEN PERIOD OF TIME. DCHD 10/95 �ry.�}''��.n�ii+,' 'e«:i.: 1 '•" �...,.:t-r,•.f'T._: c._�n -'„`i _�✓IY •y. 'y,..Il: - .. _ n _ —.. DAVIE COUNTY HEALTH DEPARTMENT . IMPROVEMENT PERMIT and OPERATION PERMIT IMPROVEMENT PERMIT **NTE** 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 .19N Sewage Treatment and Disposal Systems) PROPERTY ADDRESS /�a n-A e.r�!`� • DATE 1 . LOCATION -p 1 SUBDIVISION NAME ( -= 2. A cre,S LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE , yr i # BEDROOMS # BATHS 4? # OCCUPANTS GARBAGE DISPOSAL: Yes(„) COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE TYPE WATER SUPPLY _ DESIGN WASTEWATER FLOW (GPD) J�4 NEW SITE 4--" REPAIR SITE SYSTEM SPECIFICATJONS: TANK SIZE /)J GAL. KNI TANK GAL.,,TRENCH WIDTH S ROCK DEPTH LINEAR FT. s7DC% OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: '`' ***THIS PERMIT IS SUBJECT TO !EVOCATION IF SITE PLANS OR THE INTENDED USE CHANE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. IMPROVEMENT PERMIT BY **CONTACT A REPRESENTATIVE OF THE DAVIE COLINTY TH. DEI�ARTMW,fOR FII,NAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:38 A.M. OR 1:�-1:30 P.M. ON THE DAYfiNST(LCATION. �EL`E/PHONE`#�S (704) 634-8760. OPERATION PERMIT Y SYSTEM'INSTALLED BY AUTHORIZATION NO. OPERATION PERMIT BY j DATE **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLIN IOMPLI�c E WITH ARTICLE ll OF G.S. CHAPTERJ36A, SECTION .1900 'SEWAGE TREATMENT AND DISPOSAL SYSTEMS', BUT SHALL IN WA� �E'Tr EN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 10/95 • �� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P \ Davie County Health Department Environmental Health Section OCT 9 1 , P. O. Box 665 Mocksville, NC 27028 EIlV1ROrIfdEflTAI HEAM 0AE COUtitY 1. Application/Permit Requested By / 7� Mailing Address /Log Home Phone c3`t—1373ffg E` Business Phone 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation i eptic Tank Installation Permit ; 4. System to Serve: Ouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ IndMst ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision I�,1 Section Lot # ❑ Basement/Plumbing No.of People ❑ Basement/No Plumbing E. No. of Bedrooms 3 ❑ Washing Machiney. No. of Bathrooms Z ❑ Dishwasher Dwelling Dimensions Z 7 ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type f No. of People Served No. of Sinks No. of Commodes No. of Urinals f No. of Lavatories No. of Water Coolers �f No. of Showers Water Usage Figures " j:. 7. Type of water supply: 'ublic ❑ Private ❑ Community E 8. Property Dimensions ZZQ t<3190 Sewage Disposal Contractor t 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No If yes, what type? 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. r. PROPERTY INFORMATION REQUIRED: Directions to Property: Tax Office PIN # -.5-gw Road Name Box # (if available) ( ad 4Z;i� City !: i i 1 i i i i This is to certify that the information provided is correct to the best of my knowledge, anI understand I am r ponsible for all charges 1 incurred from this application. /-'-- 9 S' DATE SIGPXfURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. pal DO NOT OWN the property. If you checked Box#2,the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representativni/the D vie Co ty He Ith Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine said sit6's suitability f a ou absorpt' n sewage treatment and disposal system. n LA0 r/1 - PS Q ^ 7 S DATE SIGNATURE DCHD(1193) p1 A C t DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section J,6 Soil/Site Evaluation NAME DATE EVALUATED ADDRESS PROPERTY SIZE Y,'Ile PROPOSED FACIILTY LOCATION OF SITE IU�l�viy�/ Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit ✓ Cut FACTORS 1 2 3 4 Landscape position L Sloe % 2 HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture groupC 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: Al LONG-TERM ACCEPTANCE RATE: lo, 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