253 Spillman Rd , ' . , DAVIE COUNTY HEALTH DEPARTMENT �'/y�� z
� Environmental Health Section �
' P.O.Boa 848/210 Hospital Street
, ' . � Mocksville,NC 27028
� (336)751-87C0
IMPROVEMENT/OPERATION PERMIT
Account #: 990001202 Tax PIN/EH#: 5853-60-0527
Billed To: Bryan Rominger Subdivision Info:
Reference Name: Bryan Rominger Location/Address: Spillman Road-27028
Proposed Facility: Residence Property Size: 350'x 450'
ATC ty�mb�er: 3247
**NOTE** �s mprovement/Operation Permit DOES NOT authorize the construction ofa 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 I5 SUBJECT TO REVOCATION IF SITE PLANS OR TI�INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type�� #People oC #Bedrooms_�_ #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) o�C y� Site: New I(� Repair❑
System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width �'6� Rock Depth l2��Linear Ft.�f
Other:
Required Site Modifications/Conditions:
INIPROVEMEKT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF G "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(33C►)751-8760.****
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Environmental Health Specialist's Signature: ! Date:�L���_
DCHD OS/99(Revised)
• •� • / ��
• . DAVIE COUNTY HEALTH DEPARTMENT �
' , � � Environmental Health Section
r.o.Bog sasnio x�p�r�i sr�eet
Mocksville,NC 27028
(33G)751-8760
Account #: 990001202 Tax PIN/EH#: 5853-60-0527
Billed To: Bryan Rominger Subdivision Info:
Reference Name: Bryan Rominger Location/Address: Spillman Road-27028
Pro osed Facilit : Residence Property Size: 350'x 450'
ATC Number: 3247
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLJST BE ISSLTED 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,Sect' n.1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATE O TRU TI S VALID R PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: bate: ��/ /'�
CERTIFICATE OF COMPLETION
�
**NOTE** The issuance ofthis Certifica Co tion shall indicate the system described on Improvement/Operation Permit
has been installed in ompliaxLc wit icle 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and
Disposal System , s a in �Y be taken as a ee that the system will function satisfactorily for any
given period of�
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Septic System Installed By: .. ��� �+
Environmental Health Specialist's Signature: �G�(� Date: �� 1�f 2 �
DCHD OS/99(Revised)
, � : �{ � � U � �
� - _ �• • � � o 'J APPUCATION FOR SITE EVALUATION/IMPROVEMFM PERMIT&A
' � �, ��y Davie County Health Department
� ' �� � ` � Environmenia/Hea/th Section r
� �,_ �Zt��?
0 �� P.O. Box 848/210 Hospital Street .
_,Q( Mocksville, NC 27028
,��� (336)751-876o ENVIRONMENTAL HEAL7H
DAVIE COUNTY
***IMPORTANT*** THIS APPI�ICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORI�TION IS PROVIDED. Refer to the INFORI�,TION BULLETIN for instructions.
1. Name to be Billed �e/j�� % o�rrU�e2 Contact Persoa _ �Q�'L ![�O/l1�Al(',�,
Mailing Address �7`! s�/(�G�lJ,9�� �Y Home Phone _ ��—a7 ��O a
, City/State/ZIP ��,e,SviLc.e ./�. C-. �7o2g Susiness Phone ��p�p �9/��
2. Name on Permit/ATC if Different than Above �l��jJ G, �O/J'// /Geje
Mailing Address �'7�'I ��O/GL/1'l.B�II � City/State/zip �qG',�SU/CG8 ��� ���1�
�tT,��, l._�d-�.� L ,/
3. Application For: GY�te Evaluation ❑ Ifnprovement Permi.t/ATC ,�1 Both
4. System to service: �iouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. if Residence: # People 2. # Bedrooms � p Bathrooms z
I�Dish»asher f_1 Garbage Disposal f�l Washing Machine fJ Basement/Plumbing f.l Basement/No Plumbing
6. If Business/Industry/Other: Specify type # People A Sinks
�f Commodes p Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gaiions per aay)
7. Typa of water supply: 0%unty/City ❑ WeZl ❑ Community
a.. Do you anticipate additions or expansions of thc facility this systcm is intcnded to serve? ❑Yes 9-�a
Ifycs,what type?
***IMPORTANT***CLIENTS MUSTCOMPLETCTHE REQUIRED PRQPERTY INFORMATION REQUESTED
BLLOW. �ither a PLAT or SIT�PLAN MUST I3ESUBMI7TED by tl�c clicnt with THIS APPLICATION.
? t
Property Dimensions: J.?S � 7C �/S � WRIT�DIRGCCIONS(from Mocicsvillc)to PROPGRTY:
� •
TaxOfficePIN: # •58�3-6�- pS,�'7 � '�� L�ST' T S70/ L-X/T�, .lJO�T�3'
Property Address: Road Name ��ILG�I� �cv� Dy �O/ .3�L 1f?� T��tJ �6r�'?'D�i�
City/Zip /��l7C�Cd 1/�LLG��.0 �7d Zb� S�/Gc�1,s�/ ,� �,. L�/a---�L iyl/ fJ.�/
If in a Subdivision providc information,as follows: G2�� ` `
Namc: !�v :
Section: ` Block: Lot: Date Property rlagged: ��� �6 Z_
Tliis is t�►ccrtify tl�at the information provided is correct to the best of my Icnowledge. I undcrstand tl�at any permit(s)
issucd t�crcaftci-`are subjcct to suspension or revocation,if the sitc plans or intendcd use changc,or if the information
- submittcd in this apptication is falsified or changed. I,also,tutdersta�td t/ta1 I ant responsib/e jor a!/c/rarges itrcr�rred jronl
r�,�s anrrt�Ar;o,,. I,hereby,give consent to the Authorizcd Representative of thc Davie County Health Department
b cntcr upon abovc dcscribcd property locatcd in Davic County and o�vncd by
to conduct a11 tesiing proceciures us necessary to determine the site suitability.
DA7'G :���—DZ SIGNATURG ���Gry
TH1S AREA MAY BE USED FOR DI2AWING YOUR SIT�PLAN(Include all of thc following: Existing and proposcd
property lines and dimensions, structures, setbacks, and septic locations).
. Sitc Revisit Cl�argc
/ .: Datc(s):
- . . � � ��° �' �
�o � �� . _ _ Clicnt Notitication Date: . �
� �U _ �� . . U _ CHS: _
� _..
. � Account No. � �
�2[ Le�- P ��C�ivyJ �1.��f c�L
Revised DCHD(07/99) � • [nvoice No. � �
,,
,
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c�l �
• . DAVIE COUNTY HEALTH DEPART'MENT
. . ` ' Environmental Health Section
� � Soil/Site Evaluation
APPLICANT INFORMATION , PROPERTY INFORMATION
Account #: 990001202 Tax PIN/EH#: 5853-60-0527
Billed To: Bryan Rominger � Subdivision Info:
Reference Name: Bryan Rominger Location/Address: Spillman Road-27028
Proposed Facility: Residence Property Size: 350'x 450' Date Evaluated: $�"�QZ
Water Supply: On-Site Well Community ` Public t�'
Evaluation By: Auger Boring Pit � ' � Cut
FACTORS 1 2 3 4 . 5 6 7
Landsca e osition L. ,L
Slo e% :
HORIZON I DEPTH � . v i, •. •,
Texture rou SC''� CL �"C
Consistence
Structure
Mineralo
HORIZON II DEPTH �� � � - ` 15 '� "
Texture rou C
Consistence f / �
Structure � /
Mineralo �` / .� �
HORIZON III DEPTH � d•- ,�' ��• � ',
Texture rou
Consistence
Structure
Mineralo �
HORIZON IV DEPTH �
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE , �
SITE CLASSIFICATION: EVALUATION BY: (/1'�,/
LONG-TERM ACCE CE 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-Subangulaz 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
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Septic ield�asamant
Co�unencing ac apoint in the contar�ine of Sp►11�an Road(SRI458)said point being chc
southeaat corncr of Dood Book 104 Pa 876 as recordcd ia the navie Ccunry Rcgistcr oi
Deeds f3fficG North Carolina;Theuee 'th the Southem lina N 8'7°w 3Si'to a point in '
the line;Theuce�N 02°30'E 14'to the oint of Begi�u�ing�thc Southoast comer of tha
. . . . proposod stpdc 8eld oasc:nent aroa. Th e N 87°W 100"Ttuo�aoe N 02°30'E 9Z':
� Therice S 87°E I DO';Thence 3 02°30' 92'to the point�und pt�c�of Be�in�
containing O.ZI acres+!-. Beiag purt o Willlaai E Romingar snd'wife,Patricia l.
Romiager Property as rccordvd in Deed aok 95 Page 808 aad Dcod Baok]04 Page 876
with thi�septic 5cld easement there is a 10'srpde pipe easeznent zunnimg fresn tfia
. Norchesst aorrcar of the above meation scptia field N 10'E tfl the adjoiaing propescy of
William E.Rom's�get and�vife.PaMcia ..�tomi�p,ger Tax Y.ot 0527 as rocorded in the
Davie CouatyRtgsaur of Ucoda. Tho tua110'septic pipc essmnont to nm elong tha
pipc as sctualiy ptaaoci in the g�und
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