218 Pepperstone Dr Lot 14 r, ORZATION NO: -1464• DAVIE COUNTY HEALTH DEPARTMENT ✓XO.
. " , ' 2.t` Environmental Health Section PROPERTY INFORMATION
Pertmttee�s �j * r . P.O.Box 848
Name: /� !3[Jl7Jd�?Q/ " 0 Mocksville,NC 27028 Subdivision Name: Ave
Phone#:704-634-8760
Directions to property: � 411 de/ /� Section: Lot:
AUTHORIZATION FOR
SYSTEM CONSTRUCTION
WASTEWATER Tax Office PIN:# � � -IO - �03 `
Road Name: � �'�p7dt�
**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
(In compliance with Article 11 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.
NVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
t .;� '., r �..>: � _. . ..,t ,�.-. :�:._ Y- _tet` t -. ,�.. -. _ - -.• .- .,. ,. _
r 1464 DAVIE COUNTY HEALTH DEPARTMENT �Xa.
4 ..= IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Name: A � Subdivision Name: AMP-
Di e-ctions to
MP-Directions-to property: Al Section: Lot: A
IMPROVEMENT
PERMIT Tax Office PIN:# �
Road Name:
**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/mstallation of a system or the issuance of a building permit.
(In compliancewith Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***TIM PERMIT IS SUBJECT TO REVOCATION IF SITE
j 7j' j\i j, �<:�y' 'ti f•/�l~ 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 #BEDROOMS-#BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE�- #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE/1d26G TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) l/ NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANKS P ANK GAL. TRENCH WIDTH ��. ROCK DEPTH �� / LINEAR FT.F49
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
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 THE DAY OF INSTALLATION.TELEPHONE#IS(704)634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
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AUTHORIZATION NO. �OPERATION PERMIT BY: oil
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBE VE HAS BEEN INSTALLED IN COMPLIANCE
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)
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT &ATC
Davie County Health Department
Environmental Health Section
P.O. Box 848 NEW PHONE NUMBER:
29 ��$ Mocksville,NC 27028 EFFECTIVE MARCH 22, 1998
336 751-8760
(704) 634-8760
Rule MAL ViN
****I OR
APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
r
1. Name to be Billed dQ S .4A"e-- Contact Person
Mailing Address ky W61
p Home Phone_Cl
City/State/ZipU C Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: [ ]Site Evaluation [ ]Improvement Permit&ATC Vkg'o-th
4. System to Serve: W'H' ouse [ ]Mobile Home [ ]Business [ ]Industry [ ]Other
5. If Residence: #People #Bedrooms_ 3 #Bathrooms :9- [/dishwasher[ ]Garbage Disposal
v-1 oWhing 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: [!'County/City [ ]Well [ ]Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes [ "No
If yes,what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED:***IMPORTANT*** lam OF THE PROPERTY MUSTREQUIRED: BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: �d�q� �d / WRITE DIRECTIONS(from Mocksville)TO PROPERTY:
Tax Office PIN: ##� cf - - ; �� :Ze2 4&$V JZ Z- Ta
Property Address: Road Dame e L
City/Zip G
If in Subdivision provide info mation,as follows:
Name:
Section: Lot#: '
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 / q to onduo all testing procedures ecessary to determine the site suitability.
DATE 6— N��— SIGNATURE
Revised DCHD(06-96)
THIS AREA MAY $E USED FOR DRAWI YOUR SITE PLAN:
Me.�a �
1
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^ DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section 1,J
Soil/Site Evaluation 7
NAME '�� DATE EVALUATED�D�
ADDRESS PROPERTY SIZE �a1�
PROPOSED FACULTY , ��� LOCATION OF SITE ���er
Water Supply: On-Site Well Community Publicy
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position L .L
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH G F T +�
Texture groupG
Consistence
Structure Lam/
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 RATEL
SITE CLASSIFICATION: �� EVALUATED BY:
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-Finn 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
Mineraloizy
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 watet' 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
� R R 688.13'
r PUBLIC / T 45.00' T 100.00'
I' 20' PQy� L 88.50' L 188.61'
3 87-32b4. C A
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— — _ — �• s 82.18'07r E 200,
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N 84
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" " 67, w t+o.1r GRAPHIC SC
_ r 100 0 50 100 2C
MINIMUM BUILDING SETBACK
50' FRONT _
! 30' REAR ( IN FEET )
15' SIDE 1 inch = 100 M