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151 Spillman Farm Trail '�• .� -' � " DAVI�COUNTY HEALTH DEPARTMENT PG�r � �� Environmental Health Section �ol�� P.O.Boa 848/210 Hospital Street Mocksville,NC 27b28 (336)751-8760 Account #: 990004130 Tax PIN/EH#: 5823-27-1420 Billed To: Patrick Spillman Subdivision Info: /51�p;//�,�� R/'��liL ��'4T� Reference Name: Location/Address: �p� Proposed Facility: Residence Property Size: ATC Number: 4528 As stated in 15A NCAC 18A.1969(5) �ccepted Systems may also be used AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSLJED 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.1 T ent and Disposal Systems). THIS AUTHORIZATION FOR WAST ATER CTIO S LI A PERIOD OF FIVE YEARS. Environmental Health SpecialisYs Signature: ate: b CERTIFICATE OF COMPLETION **NOTE** The issuance of this 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 that the system will function satisfactorily for any given period of time. � �� 4 �S `P �Z ' 2�' c�we� -'j��I t�e,.`S� � � � �coo �� T zz ' �> a� C2��4-��C�,,g� I ' ' � 5�t�:ra+�k'�kT`� 'Z.Z ��"=' � , Septic System�nstalled By: �"��� `L�- 9 , Environmental Health Specialist's Signature: Date: �(p , DCHD OS/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT ' '" -' Environmental Health Section ,� . _-.� ,. P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 990004130 Tax PIN/EH #: 5823-27-1420 Billed To: Patrick Spillman Subdivision Info: Reference Name: Location/Address: Blevins Road-27028 Proposed Facility: Residence Property Size: ATC Number: 4528 **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 CONTRACTOR MUST SEE THIS PERMTT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type T�1�'� #People � #Bedrooms 2 #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 ��`G�5 Type Water Supply WF-I-I� Design Wastewater Flow(GPD) �a Site: New�Repair❑ System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width��� Rock Depth �Z� Linear Ft. �j0� ;�,e As stated in 15A NCAC 18A.1969(5) Other: � kJ�T��T1�1� �.�� � accepted Systems rnay also be used Required Site Modifications/Conditions: 't���1,1� Qn�J C,���� C�G�' ���P�W�'1�.. �� t� p�Y� v�S IN[PROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6•�BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Departrnent for final inspection of this � sys��en 830 a.m.to 9:30 a.m. or 1:00 p.m.to 130 p.m.on the d�of installation. Telephone#is(33C►)751-87G0.**** I �� , � 1t3�-�-- Cas�,p+����,QuoP) C �,� �, -_�- �J y '�� , � +�� ��, ., '�1-Rp.>i � ac.��,x`2. ' O � �c� s 9�� � � � ' �t�►RL=�C�1 �132„ `�o�� �a,l� �� �.���S �� o�,� Environme tal He th Specialist's Signature: Date: � �� � DCHD OS/99(R ised) � � _ . � s • . . ',�.. ` • . � 'APPLIC SITE EVALUATION/IMPROVEMENT PERMIT & ATC � � � Q Davie County Health Department D Environmental Health Sechon , 9 2Q06 P.O.Box 848/210 Hospital Street QC� r ' Mocksville,NC 27028 �,���Ep�N ' (336)751-8760/Fax(33�751-8786 - �NRONME�UNr � App 'cation For: �A a uation/Improvement Permit ❑ Authorization To Construct(ATC) B� oth ***IMPORTAN7***THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BiJLLETIN for ins'tructions. APPLICANT INFORMATION � � Name to be Billed �����C� � //ll'�1 R It� Contact Person � �'Yl� Billing Address 3� U l,t//'ylfY� /7 • Home Phone 33�~ZS/-3� �City/State/ZIP_ya d lc•n V'NQ , /✓G , 2?�S� Business Phone 331�—7�/� �1 � � Name on Permit/ATC if Different than Above ��'j�� Mailing Address City/State/Zip PROPERTY INFORMATION ` NOTE: A survey'plat or site plan must accompany this application. - (Pernut is valid for 60 mon s with site plan,no expiration wit com lete,plat.) Street Address___�✓%/VS �� City (A Tax PIN#,�� � U Subdivision Name Section/Lot# Lot Size .� � D'rections T Site: , �� � Y � S2S S� %/' � � - �tJ i/ e S��l!m �1 s n1 Date House/Facility Corners�F agged /d—��� _ � 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? OYes B�Fo .�� Does the site contain jurisdictional wetlands? ❑Yes B'l�o ' Are there any easements or right-of-ways on the site? ❑Yes�No Is the site subject to approval by another public agency? ❑Yes L1FTo Will wastewater othei than domestic sewage be generated? ❑Yes 8"l�0 IF RESIDENCE FILL OUT THE BOX BELOW ' #People #Bedrooms �_ #Bathrooms Garden Tub/Whirlpool es ❑No _ Basement: ❑Yes C�� Basement Plumbing: ❑Yes C��3� IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBnsiness Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals � Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) ' FOODSERVICE ONLY: #Seats Type system requested:-B�Conventional ❑Accepted ❑Innovative ❑Altemative ❑Other W r 1 T e: ❑ Coun /Ci Water ❑New Well xistin Well ❑ Communi Well ate Supp y yp ty ty g ty Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes C9�o If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my lrnowledge. I understand that any pernut(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 ihat 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 etermine c pl'ance with pplicable laws and rules on the above described property located in Davie County and owned by � � �� �� � -�— Site Revisit Charge operty owner's or owner's legal representative signature Date(s): . � (7.-q r ��� Client Notification Date: �Date � EHS: Sign given es ONo Account# �c�� Revised 2/06 Invoice# � ��a.�:" j' *,r`?x�,,�,�° t^::. +�,'�,�te��'�",i��. -�f .., �','�","�-�'� �. w�'��"�",oY�+� � r�g4"�'`��� � �•'°, ��� I �,� `x' ,c �'4 ? � ��' '�.�•, � � '' k `���r .� �a w "� ,_ a�:`�'� s°� 3 �s �.�� �w5 a a .t _ g s'�; �w >,�� �' � : �. .��s ��„� ��r�`��"'��"", �r��,u�' , t ���� s�� ��' � � � '4 � g,�'' a��� � � ��3 f I �� � , x .r *� e ��va+s a �+�x t �yk�' a ����°i�a+*� ,y��s� ��,�,.- e a.d"� ,� �°� � �,�„» 's� „ „ �y^.�P pa. �„"< � + �':�� '�°� �., `� 4N�?�r� � ��� � � �ip�' ��%r�}g�.'$ `b�i fi� G ➢ NP�� "a.� i'I p"� �^ 1 �F ,e a„}+�r•�' � ���".�'�^b� ,� �� R I ��' w?,����&�,:'�3 �, �'M � �`^�,�� i S �',� '� ✓'i �a� �a � '' p��#w r'..�.x}� �a���' ,f� ����� , �i;fa� ��'�+ ';'E.%�� � �u '� '� � �� . 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D�AVIE COUNTY HEALTH DEPARTMENT . . .. , _ , . ' � � f ; � Environmental Health Section ,. � ` � ' , , � � } , ` , Soil%Site Evaluation . ' �� � APPLICANT INFORMATION � PROPERTY INFORMATION Account #: 990004130 ` `:', � Tax PIN/EH#: 5823-27-1420 . , , . - . , . , •: .:_ ,- ' Billed 70: Patrick Spillman ` ` ` Subdivision 1nfo: , � ' Reference Name: . ' Location/Address: Blevins Road-27028 Proposed Facility: - Residence Property Size: Date Evaluated: 1�? 9 9!l 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. - � Slo ' %� � j�, � � HORIZON.I DEPTH : . � — � — p:��2 p .-� ,_::',:,;Texture rou ° . :Gl <SC L CL $G�- _ .��'�Consistence � � ,Structure `- ,,,. � . _. .:_ .. ... ; '.,.�`.,'Mineralo , . � • HORIZON II DEPTH ', - � • ` Texture rou - :'L �:; ' Consistence . F: . F� . ; Structure ; C �� Mineralo �, ' � HORIZON III DEPTH - • . Texture rou l ; � , � '::�Consistence Fi' � �'�:°.'Structure S C „ _ '.: '';Mineralo •, . " . . • 5,�, , . > �- HORIZON IV DEPTH Lf , Texture rou " :CLtS�. " Consistence � . �r S+�P ' " Structure' Mineralo S.. ``:;:: SOIL WETNESS _— , � �` RESTRICTIVE HORIZON " _ SAPROLITE : • -- "— CLASSIFICATION LONG-TERM ACCEPTANCE RATE O• �� O,� � �� . SITE CLASSIFICATION: T � EVALUATION BY: P . , --r- � LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: � _ REMARKS: . . � _ LEGEND ; �� T.andscape Pocition , � � 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 � . � TC3C�ilT� ' : . , S-Sand LS-Loamy sand SL-Sandyloam 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 CON4ISTF.N , _ �415� • VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm ' ,}�.t _ � NS-Non sticky SS-Slightly sticky �S-Sticky . 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(33�751-8760/Fax.(336)751=8786 Improvement Permit Patrick Spiliman 3340 Bowman Road Yadkinville,NC 27055 Re: 5 Acre Tract/Spillman Fann Road(Bethesda LnBlevins Rd) Tax PIN: 5823271420 Dear Client(s): T'his 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. System To Serve���Wastewater Design Flow(GPD):;�Valid: �Years ❑No Expiration SystemType: �nventional ❑Accepted ❑Innovative ❑Alternative ❑Other Site Modifications/Permit Conditions: �� o��A�'�C Y� Site Plan � ,+� �''f''�t = C�."� � �� Dt't�, �-E — � � �55 ��r i� � r�,�� � �- �J� ��`�''�a���i) � .. a,3 � l D z�; ,o� e p i ist Date i.p.letter 7/06