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252 Main Church Rd (2) • . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990004005 Tax PIN/EH#: 5449-09-9431 Billed To: Clyde Scott Subdivision Info: Reference Name: Location/Address: Main Church Road-27028 Pr000sed Facility: ATC Number: 4481 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 CO UCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation 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 that the system will function satisfactorily for any given period of time. �'j,,414oW, su6m i lko( b y 0d17h--d>0AZ-. Gf Septic System Installed By: W!�l/�� y 1CIU��Pf s• ��C��Q� C1 d�I�n(,r Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) 05/30/2007 14:03 3362846188 SPILLMANS PAGE 01 /ilc7r.'� (A. /Z 12 -�foA4- U. �t o. o D ECEO E MAY 3 0 2007 ENVIRONMENTAL HEALTK DAVIE COUNTY DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section P.O.Boa 848/210 Hospital Street fd Mocksville,NC 27028 ro (336)751-8760 �� IMPROVEMENT/OPERATION PERMIT Account M 990004005 Tax PIN/EH#: 5449-09-9431 Billed To: Clyde Scott Subdivision Info: Reference Name: Location/Address: Main Church Road-27028 Proposed Facility: Residence Property Size: See Map ATC Number: 4481 **NOTE**This Improvement/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 CO TOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People _ #Bedrooms Cy #Baths Dishwasher: Garbage Disposal: ❑ Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size '` Type Water Supply Design Wastewater Flow(GPD) Site: New,T Repair❑ s/ System Specifications: Tank Size,/��GAL. Pump Tank GAL. Trench WidthTi Rock Depth Linear Ft.cs�1SO Other: As stated in 15A NCAC 13A.1Q89(5� - W WW a Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISERS)IF 6 11 BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Departmen for final inspection of this 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. Telept one# s(336)751-8760.**** Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) APPLICr•` R SITE EVALUATION/IMPROVEMENT PERMIT & ATC v . Davie County HealthDepartment Environmental Health Section 2006_ P.O. Box 848/210 Hospital Street - 7�Q5 Mocksville,NC 27028 -' (336)751-8760/Fax(336)751-8786 �J '1ENjA1.HFA��1 A lication IFPI' t a ion/Improvement Permit k'Authorization To Construct(ATC) ❑ Both * PORTANT***THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed Contact Person C. Billing Address Home Phone City/State/ZIP Business Phone 3 5<:§: �►,� V Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION . NOTE: A survey'plat or site plan must accompany this application. _ (Permit is valid for 60 months th site��'}�an,nno expiration with coZ leet�e plat jl ,l Street Address_��A/ f�/ f/JtG Lt' 9t, 2 ty r`� 2!/J�l�/ Tax PIN#e 7l Subdivision Name Section/Lot# Lot Size Directions To iter 2 ate House/Facility Corners Flagged If the answer to any of the following questions is"yes",supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes DNo Does the site contain jurisdictional wetlands? ❑Yes EMo Are there any easements or right-of-ways on the site? ❑Yes DNo Is the site subject to approval by another public agency? ❑Yes Flo Will wastewater other than domestic sewage be generated? ❑Yes..QNo IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms -3 #Bathrooms 2 Garden Tub/Whirlpool ❑Yes o Basement:❑Yes ) No Basement Plumbing: ❑Yes ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People #Sinks I #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested: Vnventional ❑Accepted ❑Innovative ❑Alternative ❑Other .� Water Supply Type: County/City Water ❑New Well -- ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes No If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed. I understand that I am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to _ete a com liance with applicable laws and rules on the above described property located in Davie County and owned bye lU5 t LlSt7�) CSr?lL�. Site Revisit Charge Property o er's or own;A legal representative signature Date(s): Client Notification Date: Date EHS: Sign given ❑Yes /O Account# Revised 2/06 Invoice# - DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section r Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990004005 Tax PIN/EH#: 5449-09-9431 Billed To: Clyde Scott Subdivision Info: Reference Name: Location/Address: Main Church Road-27028 Proposed Facility: Residence Property Size: See Map Date Evaluated: Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L. Sloe % HORIZON I DEPTH Texture groupS' Consistence Structure Mineralogy "1 HORIZON II DEPTH r/ �✓ Texture group C, G 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 SITE CLASSIFICATION: !/N EVALUATION 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 VFR Very friable FR-Friable FI-'Firm VFI-Very firm EFI=Extremely firm 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 Miner oalo�v 1:1,2:1,Mixed Lists 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 05105(Revised) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■NONE■■■MIRRmill■■ ■■■■■■■■■■■t■■■■t■■■■■■ M■■■■■ ■■■■■I■ ■■■■■■ ■■■■■■ ■■■■■m ■■■■■■ ■■■■■■ ■■■■■■� ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ' 1M 172 610 126 0 138 26- d- d. (98) w (148 5558 0 o _ 5749190318 6571 X500000021 1 .01 A` M _ N 2520 (1 52A) M f �6 M 7 8424 (1 .03A) 0318 `o 168 5 49099+3 J (133) s j M N LW AME ZION CHURCF 1 .063A 5234 �?�� coJ N 3287 s (1 .46A) �o� 2127 M ' Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville,NC 27028' (336) 751-8760/Fax(336) 751-8786 June 23,2006 Mr. Clyde Scott P.O. Box 34 Mocksville,NC 27028 Re: Main Church Road Tax Pin#: 5449-09-9431 Dear Mr. Scott As requested, a representative from this office visited the above site June 23, 2006 to perform a site evaluation. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans or the intended use change. Improvement Permit System To Serve: / Wastewater Design Flow: S�� System Type: ❑Conventional RICZcepted ❑Innovative ❑Alternative ❑Other System Location: G�/�i� �`oL (� Valid: ears ❑No Expiration Site Modifications/Permit Conditions: Environmental ealth Specialist Date ps-i.p.letter 2/06