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348 Shady Knoll Ln � � DAVIE COUNTY HEALTH DEPARTMENT //�� ���� Environmental Health Section P.O.Boz 848/210 Hospltal Street ; , Mocksvllle,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001065 Tax PIN/EH#: 571&11-3291 Biiled To: Janice Peeler Subdivision Info: � Reference Name: Janice Peeler Location/Address: Shady Knoll Lane-27028 Proposed Facility: Residence Property Size: 3 Acres **NOT�*'N�is�mpr vem�ent/Operarion 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 Treatraent and Disposal Systems). THIS PERMIT LS SUBJECT TO REVOCATION IF STTE PLANS OR T�IlVTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THLS PERNIIT BEFORE INSTALLING SYSTEM. Residential Spacification: Building Type H d J�� #People 2 #Bedrooms 3 #Baths z• � Dishwasher: � Garbage Disposal:❑ Washing Machine:�Basement w/Plumbing: � Basement/No Plumbing. � Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � Lot Size ��'��s Type Water Supply IJI�GI-V Design Wastewater Flow(GPD),��D_ Site: New�Repair❑ System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width�� Rock Depth 1Z• Linear Ft.�-'a' orher: 1 �s��j��.� c��-�c� �.�sTa�L �,ac� Qt�o.c, r��,�. Required Site Modifications/Conditions: 1�5��-L- �� �''Sto� � �C"7� �.on.- �.J�.t- IL�t=� �p� ��0� ua� IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6 K BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis 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.**** ��V� ��m,,�, T / �� �� �., � . o �, ��� ,. L -1 c� � �� z7, ��--�lo inn„�. �2f��.�Q C.i�J.--� �� �r�mental Health Specialist's Signa Date: 7 0 e P�,v� /N a' � DCHD OS/99(Revised) � � /J� f ° ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/l10 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990001065 Tax PIN/EH#: 5718-11-3291 Bilied To: Janice Peeler Subdivision Info: Reference Name: Janice Peeler Location/Address: Shady Knoli Lane-27028 Proposed Facility: Residence Property Size: 3 Acres ATC Number. 2390 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLTST 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 WASTEW CTI IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health SpecialisYs Signatu e: Date: � CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate of Completion shall indicate the system described on ImprovemendOperation Permit 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 the tem will function satisfactorily for any given period of time. `Z� .•,�- � �v \�� � . ` � .a -r��� ���, � � q -3� G 15 .`��--____.--- �`�S� �y,J i Septic System Installed By: � C.�1 G �"i Environmental Health Specia]isYs Signature: Date:� � DCHD OS/99(Revised) n LS � L5 0 V `��,- _..— APPLJCA�ON�OR SITE EYALUATION/IMPROVEMFM PERMfT& C! ° � Davie County Health Department � 2 7 2��1� Environmenta/Hea/th Section P.O. Soa 848/210 Hospital Street Mocksnille, NC 27028 l �,�ywr :.,;>.;... (336)751-8760 •. ***I1�'ORTANT*** THIS APPLICATION CANNOT 8E PROCESSED UNLESS ALL THE REQUIRED INFORMATION I3 PROVIDED. Refer to the INFORMATION SULLETIN for instructions. 1. Name to be Billed ����C� 1"Ci�l,l�R Contact Peraon __�j/'(►►�� Mailinq ]►ddreas ���1(I S� ����1\�� �1/• Home Phone 33(o-'�a3J /�1'✓ �==�>�:�-w��=� �l in��'m�1-,S�4 t,�rn NC ����3 �-:��e9� n::��� 33(�-(�5�-`l�?S 2. Namo on Parmit/ATC i! Dilfareat than ]►bove Mailinq �ddreas City/State/2ip 3. Application For: ❑ Site Enaluation ❑ Improvement Permit/ATC �Both a. syntsm to sorvice: H House ❑ Mobile Home ❑ Business O Industry ❑ Other s. if ttesidence: � People _�� � Bedrooms �' _ � Bathrooms a,�_ M Diahwasher ❑ Gasbage Dieposal [Y Naahing Machiae �fl Saeament/Plumbing �Hasement/No Plumbing�� 6. I! 8usiaess/Industry/Othor: Spacify type � People # Sinka � Commodea # ShoMers / Urinala � � Water Coolers ,f , IF FOODSERVICE: • # Sests ` EstimBted Water Usage (gallone per day) 7. Type of water supply: 0 County/City EI Well ❑ Community e. Do you anticipate additioas or ezpansions of the facility t6is system is intended to serve? ❑Yes �No If yes,w6at type? � ***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED _ • BELOW. Either a PLAT or SITE PLAN MUSTBESUBMI7TED by the client with THIS APPLICATION. � Property Dimensions: 3 � � WRITE DIRECTIONS(from Mocksville)to PROPERTY: Taz OYtice PIN: # .57��� ��-3a R 1 ��� � GO �T 1�D b f�Y ��` ) Iv[ •"1. Property Address: Road Name �� S�� �J�(,L �ItuE �J ` �� City/Zip I��SIJI(,L,� oZ.���-� � . . If in a Su6division pravide information,as follows: ' Name: � � Section: Block: Lot: Date Property Flagged: �'�'2�"�U� This is to certify that the information provided is correct to t6e best of my knowledge. I understand t6at any permit(s) issued hereafter are subject to suspension or revocation,if the site plans or intended use chaage,or if the informatioa submitted in thjs application is falsiGed or c6anged. I,also,understand that I am responslble for all charges incurred from thls appllcation. I,6ereby,give consent to t6e Authorized Representative of the Davie County Healt Department to euter upon above described property located in Davie County and owned by 1�A/Yl 11,�:P to conduct all testing procedures as necessary to determine the site suitability. ;"bATE �J'��"W SIGN �RE ` � 'T�IIS AREA MAY BE USED FOR DRAWING Y S PLAN(Include all of the following: Ezisting and proposed property lines and dimensions, structures, se , a septic locations). Site Revisit Charge � �;� Date(s): p �,? , Client Notification Date: U � EHS: �� Account No. ��� F ° Revised DCHD(07/99) 5,p �0 � Invoice No. `�Ya�- � a���, �1� -�'o ��Qc�'" � r lul - � I �\I ��� �I\ 'I I _ I �� � � I � ' ___ ) ' �'� _ _ , ���,,. � , __ � , � � ' " ' � � �/, ;G� / � I � ' I , ;.. , -, ;, I , , ��� � ��� i � � �� .. ° � � � ' ' �� ► � i ��� �, � � � �' �� �� I I � � � � � II ' , . � ��, � � I . i.� 1�,'J • I I \��` 1 �/ 1, ` \ I I I � �J� ' `� /� � II ` . � � i � � C ( ' / , ,�� i i ` % i � 1 �: I � / ' Y /��� , i ; ��� . . ' / ( Vi I ', (v 1 J I � �. ':1 �.� . � � • — ------ � `� --- - _ . _-- -- — -- `I� �. i 1 � � • �' � � � 4 �t`: 1 - rv !, V � � ��� � � ,�� � � � ��' � o' I :' � � ;, � , � ; ' . �1 � f : t' , , , � , � . � 1 � i � I , I I , � / I ��,;, ,� � �.; ! � '' �;� ✓."%/� p ;`\ � / ��l/ 7'.' _1J �7VZ-�Q.; , L' . . �✓i p��i_� � , ,- � r,,. � , , , ,>;�, �- j��- � . � , i _ _� ,. _ ;� � . , >—-,:�- � � . : r�__ � � , � , � � , -,� � -- -- -- •T- . � � — � -__ � . . `_ " _ �... ,� � � �� . i . ^� - _ . .—___ . _ .. .� � — - _ - ;.s- . i r � � — . . � �`.� �. �C.eye�evl�'°'w�� % � I er _ �-____- - ; _,. \�, � _._ ..._ '�I i �\ ��.�� � --- _ � ^ � i i -` . "�✓3�ti1 _ = t . . _ DAVIE COUNTY HEALTIi DEPARTMENT Environmental Health Section ' ' ' ' ' Soi]/Site EvaluaHon APPLICANT INFORMATION ' PROPERTY INFORMATION Account #: 990001065 Tax PIN/EH#: 5718-11-3291 Billed To: Janice Peeter Subdivision Info: Reference Name: Janice Peeler Location/Address Shady Knoll Lane- 7028 Proposed Facility: Residence Property Size: 3 Acres Date Evaluated: �� °� Water Supply: On-Site Well � Community Public Evaluation By: Auger Boring `� Pit Cut � FACTORS 1 - 2 3 4 5 6 7 Landsca e osition L L L.. Slo % 3 HORIZON I DEP'TH t9 ��P o" I Texture rou C C C Consistence rSSS `S.,Q Structure C < Mineralo � 1 �� I• ( HORIZON II DEP'TH • 2 -2 ► � �S Texture rou C�1- � Consistence rS SWcture L Mineralo l; � ' : HORIZON III DEPTH 32�- Texture rou Consistence �5 Structure k Mineralo (�� � HORIZON IV DEPTH � Texture rou . Consistence Structure � Mineralo SOIL WETNESS RESTRICTIVE HORIZON • SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE O• D• SITE CLASSIFICATION: �� EVALUATION BY: v�T� 4�....—P 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 Mineraloev ' 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-gaUday/ft2 DCHD OS/99(Revised) ■����■������■■��■�����■���■■■■��■��■■�����■��■■���■��■��■■��■■ ■■� ■■■��■■���■�■�■�■■�����■��■■���■■��■■■■��■■���■■��■��s■■■■��■�■�■■ ■��■��■■o�■■■�■�■�■����■■�■■■��■��■■■■v�■���■����■�■■��■�■■�■■�■■ ■��■�����������■��■����■■s■■■■�■ ■■■■■■e����■���■■�■■�■���■■■��■■ ■�����■����■■��o�s■ea■�■e�v■■���■��■■■■■�■■s����v■■■■�■■.��s■���■■ ■�����a��■■■■■��■�■■�■■■■����������■■■■��■��■����■�■■��■��������■■ ■����■���a■��■■�■��■�■�s�■m■o■��■■�■■■■��■����o■■�s■a��s�s■����■�■ ■����■■�����■■■�■��■■����■■�■■�����■■���■■������■�■�■���■�■�■■�■�■ ■�����■■v■��oeo��ess■�■■ooso�■e�■■�■o���■���■■�■�■■o�■���■o■s0■��■ ■���■��■■�■■�■■�■s�■��■��■��■s��■��■■■■�■��■���s■�■a�■■■■■�■■■■■�■ 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