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271 Pepperstone Dr Lot 25 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section _ P.O.Boz 848/210 Hospital Street r Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001594 Tax PIN/EH M 5820-75-4454 Billed To: NC Dream Builders Subdivision Info: Pepperstone Lot#25 Reference Name: Location/Address: Danner Road-27028 Proposed Facility: Residence Property Size: 1 acre **NOTL�*'�lhIsgmprove2ment/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 oh� #People #Bedrooms_�� #Baths Dishwasher:7--, Garbage Disposal: ❑ Washing Machinee2l"' Basement w/Plumbing:❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type �T #People #People/Shift #SSea13ts Industrial Waste: Lot Size Type Water Supply (,c Design Wastewater Flow(GPD) Seo Site: NewrET' Repair❑ System Specifications: Tank Size 1[49 GAL. Pump Tank GAL. Trench Width� Rock Depth 1� Linear Ff�' Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISERS)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 pt-'. 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** p Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) clk— DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account M 990001594 Tax PIN/EH M 5820-75-4454 Billed To: NC Dream Builders Subdivision Info: Pepperstone Lot#25 Reference Name: Location/Address: Danner Road-27028 Proposed Facility: Residence Property Size: 1 acre ATC Number: 2726 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 FIAVE YEARS. Z�aEnvironmental Health Specialist's Signature: Date: -U�— CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion sh Ili dicate the system described on Improvement/Operation Permit has been installed in compliance with Article 11 S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY be t a a guarantee that the system will function satisfactorily for any given period of time. 7 Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) • DAVIE COUNTY HEALTH DEPARTMENT �( r Environmental Health Section Soil/Site Evaluation NAME DATE EVALUATED ADDRESS PROPERTY SIZE n✓�� PROPOSED FACIILTY —����/S`� LOCATION OF SITE s�/`���✓G�i' Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position 1/-- Sloe % HORIZON I DEPTH Texture group Consistence Structure MineralogX HORIZON II DEPTH r r Texture group 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: 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 ^''�'��7,�.('/ r y _ i' r -/..i ''�'.� "`... �_,le--ter _ s A�'a'•o E `'��.} s,�ss, `rrys ,� //AC LOT CURVE LG LJti 12 C12 26 C15 71013' 4.274 4.27' N61041 t + 25 C14 71933 140.22' 140.00' N 65 7'05" r- 2-+ 24 C15 7193Y 62.76' 62.74' S 84 E 24 C16 55.00' 43.56' 42.25' N 61 2'32" W f 4 23 C17 55.0(Y 35.30' 34.70' S 20'14108" E '30'48" 22 Cts 55.00' 42.12' 41.09' N 20'05117" r- 39.15, 39.15, 21 C19 55.00' 111.81' 93.53' N 790441150 W S H E ET )0.00' 20 C20 30.00' 36.22' 34.06' S 56.04'57" E 18.81, 20 C21 659.tY 94.66' 94.58' N 85.13113" E P EP P ERST 19 C22 659.13' 16.27' 16.27' S 80.23'55" W 28 C25 377.63' 99.34' 99.05' S 02 46'22" E 27 C24 :W.6Y 83.94' 83.69' S 02'4448" E SUB N/A C25 417.2Y 55.04' 55.00' S 85.54'07" E 27 C26 417.23' 112.50' 112.16' 9 82'35138" W il �Zg 0 5 GN s f6 %),OOM PAUL G. HENDRICKS OWNER ? TAX LOT 0 3.01 MAP F-3 a�rtw�t 086, DEED BOOK 162 PAGE 016 PROPERTY LINE TANGENT DATA CLAUDE 190 T 10 9G 220 $ LINE DIRECTION DISTANCE MOCKSVOI LL g10� L1 N 21.41'03" E 43.23' 9?' L2 N 34.01126" W 40.69' TELEPHONE: 0 280 0 .54,00. e RECORDED AN DEE N`9 41'29" a �, o� CLARKSV ,y0DAV I E 10 gV o , o ! r' y� ��be os,50, of '•i10x70se :r 30.73 ;U 2 CURVE * 4 N 88709105" E �- Vi;MENS 741.36' -C21 - C"p m � � g5.69 � •,` U� z : (p © ti .k N 0 tP �• ° 19 •ro is n'N 'eji �� 183.50' • APPLICATION F011 SITE EVALUATION/IMPROVE LENT PEi1MII'& t'.1 • Davie County Health Department EnldlronmentalHealtfiSection FEB 2 0 2001 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 EWRONMENTAL HEALTH DAVIE COUMY ***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 ��i} )• O� 5 CL Con tact//P�e sonny �/��/1 ��/� Mailing Address 7 / 0 /YOdl et,I-Hom Ph 3`l9 775 1 AA �M/� Home Phone �7 City/State/ZIP -V ll� 7G�L/� Business Phone zl� /- 2. Name on Permit/ATC if Different than Above 1 Mailing Address City/State/Zip 3. Application For: 0 Site Evaluation Improvement Permit/ATC U Both 4. System to service: jX House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. If Residence: # People # Bedrooms # Bathrooms _ X,Dishwasher 11 Garbage Disposal Washing Machine ❑ Basement/Plumbing Il Basement/No Plumbing 6. If Businesa/Industry/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 s. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes 0<'Vo If yes,what type? "IMPORTANT"*CLIENTS MUST COMPLE'TETIIE REQUIRED PROPERTY INFORMATION RE,QUESTED BELOW. Either a PLAT or SITE PLAN MUSTBESUBMITTED by the client with THIS APPLICATION.1 Property Dimensions: / WRITE DIRECTIONS(from Mocksville)to I'R01 ERTY: Tax Office PIN: # s92,0 -7 S Property Address: Road Name Ci:}/Lip If in a Subdivision provide information,as follows: Name: Section: Block: Lot: -2-S- Date Property Flagged: �� This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits) 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. 1,also,understand that 1 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 sit stability DATE SIGNAT THIS AREA MAY BE USED R WING YOUR SITE P (Include all of the following: Existing and proposed property lines and dimensions, tr ctu es, setbacks, and se tc locations). C41 p Site Revisit Charge Q Datc(s): w Client Notification Date: L� EHS• Account No. r Reviscd P-11.1) (07/99) tv Invoice No. `