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356 Spillman Rd ` t DAVIE COUNTY ENVIRONMENTAL HEALTH , . �' , P.O.Box 848/210 Hospital Street Mocksville,NC 27028 , (336)753-6780/Fax#(336)753-1680 REPAIR IMPROVEMENT PERMIT � AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Accau�t #: 990004378 i'ax.P1N!�H#; C6-000-00-035 Billed To: Shannon Fair Sufadivisian Info: Refer�r�ce Narne: Repair Permit LocatiortiAddr�ss: 356 Spillman Road-27028 E'roposed Fa�ility: Residence Pro�er#y&ize: 0.43 Ac �TC Nu[itber: 6060 Site Type: ❑New qQtepair ❑Expansion **NOTE**This IP/Authorization to Construct(ATC)MIJST 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 or the intended use change. Residential Specifications: #Bedrdoms � #Bathrooms #People 3 Basement0 Basement plumbing❑ Non-Residential Specscations: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size �-Y3 " Type of Water Supply: L$County/City ❑Well ❑Community Well . `.�j /8d� System Specifications: Design Wastewater Flow(GPD) 3� Tank Size��G�"iL�Pump Tank GAL. �r �r r � Trench Width 3 G Max.Trench Depth 3� Rock DepthJ� Linear Ft. 3�0 0 Site Modifications/Conditions/Other: : `�h� IC.eo��G�i v N Contact the Davie County Environmental Health Section for fual inspection of this system between 8:30—9:30a.m.on the da of installation. Tele hone# 336 753-6780. �� ") _.,, ,�� b _, � —� �_ -�. �_ � � \ r' � S I �o ` �� . � ,,,) �� � Q : � ��-- � z ° � � �'' s` . �. �I " � � � �` = , z � . ... o�a `�'�- 0 > c � � . Environmental Heal,th Specialist i!� Date: � ra 3 - /� DCHD 11/06(Revised) : ; - _ . : N � . . .;. . _ �� . . � _.- .�.,�t. �rj v 1 :F! �i . . f s.- . j�i ."�:.�f�/� ' � .'.l. �+...✓...^'' . � � . .i'. �,.y:'.. . . . . . ,:�i 4 _ .. . � , i - , . . . Pximiccee's�� [ � � DAVIE COUNTY HEALTH DEPARTMENT " -Name: '��+����1��f�7. ��/"'' EnvironmentalHealthSection PROPERTYINFORMATION ' `,�Q �� �(� ��r , / P.O. Box 848 Directiods to property: �� h4ocksville,NC 27028 Subdivision Name: �`� � ,� � �� Phone#: 336-751-8760 ► +�,G t�l U i�tA '�' '—" G n Section: LoL• AUTHORIZATION FOR ,� WASTEWATER Tax Office PIN:# - - SYSTF,M CONSTRUCTION ?��r `��:3� ��V1t c rt ,� �^ ���� AiJTHORIZATION NO: o o���� 1� Road Name: ��' Zip: � **NOTE**This Authorization for Wastewater System Conswction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Pemuts.This Fo►m/Authorization Number should be presented to the Davie Counry Building Inspections ' Office when applyino for Building Permits. . (In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) � ``�:�/� /3 ��j***NOTICE***TH1S AUTHORIZATION FOR WASTEWATER CONSTRUCTION �i'�',��r-��'��..�'''�� �— / IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED 5�����s'�.' 2 RFSIDENTIAL SPECIFICATION:BUILDING TYPE #BEllROOMS � #BATHS #OCCUPANTS J GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILTI'Y TYPE #PEOPLE #PEOPLFJSHIFC #SEATS INDUSTRIAL WASTE:Yes or No r,e. LOT SIZE��.TYPE WATER SUPPLY ��� DESIGN WASTEWATER FLOW(GPD)3�� NEW SITE REPAIR SITE V SYSTEM SPECIFICATIONS: TANK SIZE eY��'GAL. PUMP TANK-����'f .""L. TRENCH WIDTH� ROCK DEPTH 1 Z ( LINEAR FT. '6p ! OTHER � --,.` REQUIRED SITE MOD[FICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT � � =� �/�S u f-c �{ (,�a-f� -t a N � �r� J.�:�f- � � o Gt u � G u-E� (�'fi u r-e -�_ � Ll.�a r �� �, �raul� _ _ _ Q� c„� ' /�oo v1) � 'S c' a(Po� i-p -{-q E1 1� - �_YI P.�1_L'i✓7__ � �. , ,. a�'"`�'N � � �,-�. �=�+SudG di ��kr� �Y ;�� c�e��s � ' � 5 'IV P` C.IIG�' al ✓�� �f /G/t�i ��. �� . � / � 3X`- I�� G11 � � cirar� ► 4-a cRboue� ac! � , ,� s n�'w S�v1', c � � � S � J � ,,,, o �,• , o' � �(��oS�c.( h<r� #�a`i� (��('�f . � � � �' � � y � � � � � t�.l�� (-� a ,��� o • �l > � �o p � ,� � � �� O��r .� � N ' Nq X� '� � i i �v C� 'S C t��U f��O v c.' ���...r 'l Cy �j'I -� .J -a � W � � � �'L.�...,.. .. J , 1 `�v� � IUC.�V�� . a4, . ��� � � . _ _ . _ � 'd � �` .% , .. � �fq�r�' ' t. . . � �IU��.h�/f �G����t 14 d/U�`J �Gyc 'S .. �..- � _� '.o. � FOR F1NAL INSPEGTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760. OPERATION PERMIT • SYS7'EM INSTALLED BY: � � C�� ����`��l ������ � AUTHORIZATION NO. OPERATION PERMIT BY: DATE: +•TI�ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WTTH ARTICLE 11 OF G.S.CHAPTER 130A,SECI'ION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTOgILY FOR ANY GIVEN PERIOD OF TIME. �o���� .�nc-��' ,�31� .�v� � lt4� - ,�kNo�� . u • � _„ � . DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION �`3,Z$ 7g � � • APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) �� /� NAME �"�N��� ��� PHONE NUMBER Q,� �J/� �/� �\ ADDRESS��O�!7%II/YJ�/� ICLf • �!"6OC�'i��� �l� SUBDIVISION NAME � � LOT # � DIRECTIONS TO S TE -�-�� ��S-� �'�'% r/9r�%/L ��N ��!/N L��'-� �/�/(�0'� fld L �� � ( `1o�t e. � i -�u r W �D� 0'iv,� � / � 1 p � DATE SYSTEM I S �ALL D� �G NAME SYSTEM INSTALLED UNDER�N ��{�!A�l �YI NO TYPE FACILITY �.Se NUMBER BEDROOMS � NUMBER PEOPLE SERVED -� TYPE WATER SUPPLY 6 SPECIFY PROBLEM OCCURRING G!! r S�Na�/RJq /� b/�C� s�v1�ells u� e �e 6 /l/.� i/ /iN-c . DATE REQUESTED,� Z INFORMATION TAKEN BY This is to cartify that the iniormation provided is conect to the best of my knowledge,and that I understand I am rasponaible tor eil charges incurted from thia application. 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Environmental Health Section Soil/Site Evaluation � APPLICANT INFORMATIOIV PROPERTY INFORMATION �Y1 ce.r1 �o� �"oz�I' �r� -5�;1 t�.� �� ���su;i�.�, f �� �zo �� �.- i� - c�7 Water Supply: On-Site Well Community Public ✓ Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca sition Slo % HORIZON I DEP"TH � � Texture grou Consistence Structure Mineralo ; HORIZON II DEPTH Texture u Consistence Structure Mineralo HORIZON llI DEPTH Texture rou � Consistence Structure Mineralo HORIZON IV DEFTH Texture rou � Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITECLASSIFICATION: QrOv JH �Y t'.� `�C EVALUATIONBY:��� � �(?Tir7�n�, LONG-TERM ACCEPTANCE RATE: / OTHER(S)PRESENT: � REMARKS: �f/�G+�i� �—C�._ � LEGEND ' I. n s ne 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_ T�stur� � 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 . .ONSIST�,N . . NI�iS� ' VFR-Very friable FR-Friable FI-Firm VFT-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 �tuL� SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angulaz blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineraloev 1:1,2:1,Mixed �� Horizon depth-In inches Depth of fill-In inches ' Restrictive horizon-Thickness and inches from land surface Saprolite-S(suitable),U(unsuitable) Soil wemess-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 � DCHD OS/OS(Revised)