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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.**** ,- � ` ,�kis�.":J ��fC.n?er fl ?D — � ` 7Q �`, .cr� l U— 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� A �� �� .�`�� , , �Cu�' �f��' . � � �s��'�-- �`�� �S`�;►a� � � � '��/ � , �r � �� 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. � � ,, , � � q � I � � I� 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 DC�-ID OS/99(Revised) O�■�■�����■���■�����■�����■■���■�■����■���■���■�����■■■■0�■ ■��■O■ ■■����■■���■■�■■�■■��������■��■�■■��■�■■������■■�■■����■■������■1■ ■■�����������■����■�■■�����■���������■■���■������■�■�■■■�����■��■ s��■t����������■��■���■�■■����■■ ■���■�■���������■■���o�■����■��■ 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N �t �, "�"` a � �, � Ol M � \ w; F�t.� 1 �q, Z ' a O� � ~ �� ► ���7�� � � � - � � �� N?FJ- �o�� � � Q ' � � .�;._.. ... ..._� • ,� �j,...._,92' —�•� a � oZ4�p�t . � Wt�1,AYr �• Q!7lA11��G1�� � . +.� D L�� � . 3 � � �I..'TGt.\GTA,. � �a,��,� �� a,,�����R ��N � � �j,,,, . � : ��t'�fLt G�Q �:. �� �, P a� (137) � � � ���� � �. w� a���3� � � FROM� : GENE�S AUTO PARTS PFiONE Np, : 910 766 9194 , , � Aug. 21 2002 10:2BAM P2 . � iBTT A 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 I . � .