224 Bethesda Ln ' DAVIE COUNTY ENVIRONMENTAL HEALTH
` P.O.Box 848/210 Hospital Street
Mocksville,NC 27028 ,
(336)753-6780/Fax#(336)753-1680
REPAIR OPERATION PERMIT
Account #: 990005713 Tax PIN/EH#: 5823-28-3202
Billed To: Troy Spillman Subdivision Info:
Reference Name: REPAIR PERMIT Location/Address: 224 Bethesda Lane-27055
Proposed Facility: Residentila-Repair Properly Size: 3.56 Acres
AT 'i[rlryf�p*r*The sssuance of this Operation Permit shall indicate the system described on the ATC 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 function satisfactorily for any given period of
time.
(System Type:S.T.Manufacturer. ' Tank Date Tank Size
Pump Tank Size ii ,' l ��Wate:
System Installed By:� rv(411 E.H.Specialist: I �D
GPS Coordinate:
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DCHD 11/06(Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH
' P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
b',753-6780/Fax#(336)753-1680
REPAIR IMPROVEMENT PERMIT `''
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
7
Account #: 990005713 Tax PIN/EH#: 5823-28-3202
Billed To: Troy Spillman Subdivision info:
Reference Name: REPAIR PERMIT LocationiAddress: 224 Bethesda Lane-27055
Proposed Facility: Residentila-Repair Property Size: 3.56 Acres
A**&�"1'1; *��is Ip1 Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A
Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS.IP/AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat
the intended use change.
Residential Specifications: #Bedrooms #Bathrooms #People BasementD Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size GC Type of Water Supply: []County/City RWell DCommunity Well
System Specifications: Design Wastewater Flow(GPD)-Tank Size L)7Ut UAL.Pump Tank GAL.
Trench Width Max.Trench I)epthRock Depth Linear Ft. l90
Site Modifications/Conditions/Other:
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30—9:30a.m.on the day of installation. Telephone#(336)753-6780.
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Environmental Health Specialist Date:
3& I
DCHD 11/06(Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME 5j2 Iq PHONE NUMBER
ADDRESS L( !� -P h -t S'd SUBDIVISION NAME
LLO-Tx#
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED )`NAME SYSTEM INSTALLED UNDER ( CSC C,
TYPE FACILITY SF , '` NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY_-j,=I, \ SPECIFY PROBLEM OCCURRING
DATE REQUESTED 7 ✓ 1 INFORMATION TAKEN BY G`
This is to certify that the information provided is correct to the best of my knowledge,and that I understand 1 am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1193
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued-in Compliance With Article II of G.S.Chapter 130a
SanitarySewage Systems Permit Number
Name.
/rG i `i • i i 7�. t-'AK's Date i�' �/ i�� NO 7016
— �.
Location, - i `';% � % _
v �
Subdivision Name Lot o. Sec.or Block No.
Lot Size House Mobile Home_ Business Speculation
ar
No. Bedrooms-' .No. Baths No. in Family _
Garbage Disposal YES ❑ NO d Specifications for System:
Auto Dish Washer YES NO 0
Auto Wash Ma:hine YES NO ❑
Type Water Supply ��C . 1✓ �'
*This permit Void if sew_ age system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
Improvements permit by_//Z?
'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 day of completion. Telephone Number 704-634-5985.
b Final Installation Diagram: System Installed by A /
1F
{ f}?'
r"
Certificate of Completion
'The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation,but shall in NO way be taken as a guarantee that the system will function
°P9 D v
AV COUNTY HEALTH DEPARTMENT
. �
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
_
°NOTIssued inCompliance With Article U�G.S.Chapter 130a
Sanitary Sewage System Permit Number
Name Date N2 7016
Location
Subdivision Name Sec. or Block No.
Lot Size House Mobile Home Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES 0 NO El' Specifications for System:
Auto Dish Washer YES NO [3 '-)
Auto Wash Ma-.hine YES NO
Type Water Supply
*This permit Void ifsewage system described below is not installed within 5years from date of issue.
This permit iusubject tm revocation if site plans orthe intended use change.
~~_
_-
~
^
Improvements permit by '
°Contactu representative ofthe Davie County Health Department for final inspection of this ayoh*m between 8:30-
9:30 A.M. or 1:00'1:30 P.M. on day of completion. Telephone Numbnr 704'634'5085.
Final -'-'_m '-'_-_ by
`
'
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/
--__-_-__
/
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~
/
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'
Certificate ofCompletion Dote
*The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
f'
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER rr��
4
Davie County Health Department RE.? f � �®
Environmental Health Section JAN 2 8 1993
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By r'aCi J!01 —rm o.,
Mailing Address
Home Phone Business Phone
2. Name on Permit if Different than Above
3. Application/Permit for: ❑ General Evaluation Q'Septic Tank Installation
4. System to Serve: ❑ House Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home:Subdivision Section Lot #
❑ Basement/Plumbing
No. of People �' ❑ Basement/No Plumbing
No. of Bedrooms a Washing Machine
z
No. of Bathrooms ❑ Dishwasher
Dwelling Dimensions `L x b ❑ Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: ❑ Public ) 2'Private /� ❑ Community
8. Property Dimensions / Q Q/ �a�J?� Sewage Disposal Contractor 344. e- Sa- IZ4 2 r2 J
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 1K 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.
Directions to Property:
CAJd
n a-
Y6 '2Z
Cwz.o
CQ
This is to certify that the information provided is correct to the best of my knowledge,and I understand I am responsible for all charges
incurred from this application.
/-'? 8= 9 3 - Sizil QW)
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: 01. 1 OWN the property. ❑ 2. 1 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 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 said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
DCHD(12-90)
rte_
' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY LOCATION OF SITE y��
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position L
Sloe % -- - - -
HORIZON I DEPTH
Texture group
Consistence
Structure
MineralogyJ
HORIZON II DEPTH 42-9;*'
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 S
LONG-TERM ACCEPTANCE RATE 77-77---777 " f/
SITE CLASSIFICATION: _ EVALUATED BY: Y!�f
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
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