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127 Pepperstone Place Lot 26 P�a,,,,ryy n palrk:pi"c�:T"w�y+ �J°,f 'r-*•�i• x-i'°+v`r�5. v`e .art-•iy'_ - Y 3 ' U-TH,ORIZATION NO, . 14 6 6 DAVIE COUNTY HEALTH DEPARTMENT _ ✓ec o Environmental Health Section. PROPERTY INFORMATION Permittee's P.O.Box 848 . Name: e � DO Mocksville,NC 27028 Subdivision Name: f} Phone#:704-634-8760 / Directions to property:k— /13, ��.�- r Section: f Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN: �- �jj r36�4 SYSTEM CONSTRUCTTO GLC'12._ � Road Name: - ip:9 70 Z **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits.This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (Incompliance with Article`I I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) !; ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST; DATE ISSUED 4t:'-iy . .' EI"�tS.`.8.� ..v'.'Y`.+4v .4 ;.Rr { y, "� y _ .-• lei.,•.:i < . ` ., ..'.at }�. x`33 ` 466 DAVIE CO�INTY HEALTH DEPARTMENT � o IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Name` ,x l. 1/ fD Subdivision Allp a _rn i f Directions to property- Section: f Lot: IMPROVEMENT PERMIT Tax Offic PIN 4�Dp1' f371 //��C'R.. ' oad Name �Cj°!Ys%r'PAziD:7-70 Z ff **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 1 I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ,y��/~ w;� ""�� p r •-� ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. ` RESIDENTIAL SPECIFICATION:BUILDING TYPE 1-1 _ #BEDROOMS S#BATHS a #OCCUPANTS GARBAGE DISPOSAL:Yes or No. COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT / #SEATS (INDUSTRIAL WASTE:Yes or No LOT SIZE- TYPE WATER SUPPLY�� DESIGN WASTEWATER FLOW(GPD) O a NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE e Q. GAL. PUMP TANK GAL. TRENCH WIDTH�i ROCK DEPTH-JJ LINEAR FT. 5f�6 OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT f'r *"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THIS DAY OF INSTALLATION.TELEPHONE#IS(704)634-8760. OPERATION PERMIT SYSTEM INSTALLED Y: N►� f p14: i a � rt4��k o�t•�T�.'?�2.10 Sa' � F AUTHORIZATION NO. OPERATION PERMIT BY: c :��DATE: t "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT STEM DESCRIBED ABOV AS BEEN INSTALLED INCOMPLIANCE WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NOWAY BETAKEN ASA GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 05/96(Revised) • ~� 9 WAPPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT — � R ^��a Davie County Health Department R Environmental Health Section �3 P.O.Box 848 JUN — 2 MW (� 6` Mocksville,NC 27028 (336)751-8760 E�+�iTDIl4'EIITAL g �s11! O,VIE Ur ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS J ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed 41g—jnh,ed!1 IContact Person / Mailing AddressV,�,Aetl Home Phone 9�,f_ ,o .1 City/State/Zip G��St� / L �D _ Business Phone 2R " 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation improvement Permit&ATC L3 'Both 4. System to Serve: &/House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms # Bathrooms ErDishwasher ❑ Garbage Disposal gr Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage(gallons per day) 7. Type of water supply: 3 County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 1a'No If yes,what type? EITHER A PLATO I PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A% THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: l3yx rd3 O WRITE DIRECTIONS(from i-p q / Mocksville)TO PROPERTY: Tax Office PIN: # <J O CLIP Property Address: Road Name le.o G le91. &1 1 s� ndA 1 k it 01 r1dA City/Zip 1 , 1O Odd f'1 If in Subdivision provide information,as follows: 1 1 4 id 2A -e ll Name: q / 1 &,nh Le I/ Section: l Lot #: 1 1 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 C-t / C c to conduct all testing procedures as necessary to determine the site suitability. , DATE 4�O r r. �� SIGNATURE Revised DCHD(06-96) /p• ;o-a3 YOU MAY USE THE -BACK OF THIS FORM FOR DRAWING YOUR SITE PLAN. //V v, � 3/ N/A c25 417.23' 112.5(Y14At DANNFt� pr.w ... � '04" C1 302.90 , ' a- HENDRICKS — — S 28 '78'07* E 20Q.30' 8 6 47, 10-AX LOT 0 3.01 MAP F-3 PROPERTY LIQ All 1 _ C26' g I& Utility Coan} — — —~ ig GZ 5�GN �?6 eQ OO~ �. t7' ; ECD DOOK 162 PAGE 016 LINO DIR 3 10 x 70Ic, C� st p '8, "� L2 N 3 1 L1 1 4 75C4 co cp 5 ^ o 1 tS 2© '+ S 73 5410ox L% 0 280.00, 1679 Z r ` O i g 70 Of 8.37 9' ! m v G �41�29N e Z 2 °° q 170.0 ,r, 'L N 79 41� 0 z 232 �n o 0 0 i O p 79 g�39�� W o` Cts c, J '110.0vst� V! 'fl 10 x 70 Sr_ V Z30'1 N of Z 3 lei �, 31 of �0 1O ZOO PAv�µ�N c © ! _ O ° / � Z70° 120 aba pp, t — T Cos o� 'FZPve,%LG ��, VtilitN `•0� ` O `TO: r• N O .,soti,. tp _ t 19 m ? • N O � ;• tM 70.00 cQS 6 0 O 0-0 to � �•, t 5 0 w A 1 ,�:;, 115 3?� ti, '54348" O gc� 14 A 3J�� 112•p0 :: ,19.3'1 E N Q 00 112000 1 - 0 0 00, F,gIT�ew._ g p 12 O `p tt1 S� z. TAX LO� 9. 74 MAP G-3 Total 1 k DEED °°�OK 047 PAGE 206 ' � -r4t'Zo' W 1531.0 T v . ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME AG9e-aI DATE EVALUATED 6'29-9Z ADDRESS PROPERTY SIZE /n/ Y� � PROPOSED FACIILTY A << LOCATION OF SITE _SC1cg�1- Water Supply: On-Site Well Community Public L� Evaluation By: Auger Boring Pit // Cut FACTORS 1 2 3 4 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure MineralogX HORIZON II DEPTH f Texture group Consistence i 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 ESE 4( SITE CLASSIFICATION: jEVALUATED 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