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460 Spillman Rd � �'` DAVIE COUNTY ENVIRONMENTAL HEALTH `� P.O.Box 848/210 Hospital Street '. Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 • OPERATION PERMIT �cc�u�t #: 990005740 '�ax:P1�I/EH#: 5853-53-7231 . Sifle;�To: Helen Myers .. . .� ` �u�idivisiort;lnfo: � , R�fer�E7ce P.I�n�e�: � �.. , � ; � : ,LocaiioniAddre�s: 4607 Spillman:Road-27028 �.:�,: �: Propasec] Fa�;i€ity: Residential :��; , =:� � ;'; Prap��y�Siz�: 1.754 ' , . . < . f\TC Nurrtb�r: 5825 , , , **NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC 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. . t ;' .` � .System Type: S.T.Manufacturer��G t� Tank�Date s/z Tank Size /OoQ Pump Tank Size System Installed By:�/�j��(�if E.H. Specialist: ate:��p�� GPS Coordinate: C �� N7' � �,� . . a , _ i . .\" � r �33 \ � � � J _ L�'� � � � � . . .� . � . . . j:. � .. � . . DCHD 1 1/06(Revised) � , , DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street ' Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990005740 . ,:: 7�x:.PIN!EH�#: 5853-53-7231 _: ' > .��; Biflcd To: Helen Myers �!i� ; Suf�t�ivi�9�rt;�n�a: .. ,, . . Refer�r�ce N��ie: .. : � �,,:�LocationiAddress: 4607 Spiilman Road-27028, ,�: . ., ' t :.. F'rnpaserl F��:iiity: Residential z •:•� � .-: � •, �ro�eriy��z�• 1 754 ,, -,, - �. � ,� , ,. Sife Type: [�l�ew ❑Repair ❑Expansion E��I��3'his��horization to Construct(ATC)NIUST'$EISSiJED`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 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: #Bedrooms�#Bathrooms�#People�Basement0 Basement pltunbing� Non-Residential Specilications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) . Lot Size ��C�(G Type of Water Supply: �ICounty/City �Well ❑Community Well System Speci£cations: Design Wastewater Flow(GPD)��Tank Size�`�GAL.Pump Tank�GAL. Trench Width.� Max.Trench Depth� Rock Depth� Linear Ft.��/�l Site Modifications/Conditions/Other:� a� �� . Contact the Davie County Environmental Health Section for final inspection of this system between 8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760. SD' !y7' _ %' �Q�v � �, � .. ��IZ� �`' /�3� �� . C��) ' , , Environmental Health Specialist � ' Date: 2� Z��( DCHD 11/06(Revised) . � f ' ,� � _ ��l; Davie County Environmental Health . P.O.Box 848/210 Hospital Street � Mocksville,NC 27028 � ` (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Account #: 990005740 Tax PIN/EH#: 5853-53-7231 Billed To: Helen Myers Subdivision Info: Address: 841 Spillman Road Location/Address: 4607 Spillman Road-27028 City: Mocksville Property Size: 1.754 Reference Name: Propo,s,��i�t,��ent 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 l l of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. Permit Type: fj�.New �Repair ❑Expansion Permit Valid for: ❑5 Years ❑No Expiration Residential Specitications: #,Bedrooms �#Bathrooms�_#People�Basement❑ Basement plumbing❑ � Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):�_ Type of Water Supply: �County/City ❑Well ❑Community Well Site Modifications/Permit Conditions: S stem T e LTAR Initial �0 P O/1 ZS . Re air /o "2 ' q � Site Plan � i 7�� . 3,`� ...—__,. , / • � .aY ,� 1'L'rt�� .�ti ��-- ��3'� . I �a� . � �� , �� Environmental Health Specialist • Date l i.p.11-06 . . / � , fi� � � t' ' � � � - �1PPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC � Davie County Environmental Health P.O.Box 848/210 Hospital Street • Mocksville,NC 27028 (336)753-6780/Faz(336)751-8786 . Application For: � Site Evaluationllmprovement Permit ❑Authorization To Construct(ATC) ❑ Both Type of Application; �iew System ❑Repair to Existing System ❑Expansion/Modif cation of Existing System or Facility ***IMPOR7'ANT***THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED 1NF'ORMATION IS PROVIDED. Refer to the INFORMATION BULLEmIN for inshuctions. � APPLICANT INFORMATION Nacne to be Billed s Contact Person Billing Address Home Phone �q $ - (��f�(j1 � City/State/ZIl' ' Busi�one +�!o�3��9 -T- Name on PermidATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION �'Date House/Facili Corners Fla ed ��! G NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan OPlat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name � r Phone Number,�� D Owner's Address � ' 1 City/State/Zip_��r_�u, � � 1��'.� �� PropertyAddress City�a�:�c gy; ))p � Lot Size i .�''1 �5 � }�, T PIN# - � Subdivision Name(if applicable)' Section/Lot# � Directions To Site:"� ° ' • � ; �. ' a If answer to any of th following questions is"yes",sup orting documentation must be attached. � A.re there any existing wastewater systems on the site? J�'1'es�No Does the site contain jurisdictional wetlands? ❑Yes�(I'rTo � Are there any easements or right-of-ways on the site?. ❑Yes ❑No Is the site subject to approval by another public agenGy? ❑Yes�INo Will wastewater other than domestic sewage be generated? ❑Yes o IF RESIDENCE FILL OUT THE BOX BELOW " � #People � #Bedrooms �_ #Bathrooms � Garden Tub/Whirlpool ❑Yes �To Basement: ❑Yes ❑No � Basement Plumbing: ❑Yes o IF NOl�-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness 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: Q�Conventional� ❑Accepted �❑Innovative ❑Altemative ❑Other ' � Water Supply Type: C�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? Thie ie tn enrtifv that thP infnrmatinn nrnviAarl nn thie annlinatinn ic tniP anA nnrrPnt tn thP hPct nf mv irnnwlariac+ T nnr�E+rctanA that �na�a►ry permit�s�or A i L(s)issued hereai�er 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 hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and . oca ' and flagging r stakin he house/facility location,proposed well location and the location of any other amenities. Pr erty owner's or owner's legal repr entative signature - Site Revisit Charge �./ Date(s): �5 "" � - �l Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# �� V� Revised 11/06 Invoice# �,��.�� i� ; �'a�'��'�`�� c�.: � ��"'��' � ��"' ,��, ., . ;.�� &�� .q � � �1��r,:�#��a�,r��s „�� h � _ ' a.- 3 �' IiIl�I�t 1 u 7' �� afi'�,'a„ j' �� f, Y,. b , � �� r- ,�' -��' �. � � ,� � -�. - � ��' �� y' � � �al./,.� �'F_�� vC�y�' � 3 S7�y2 `;�` ' r��.a� _ d/ -4� `� r :.ib .a r"�' � w V'�� a 7�� , ,�:- � �t ?'� t ' - �- � »�� . 2.; t :;r¢.a k�l�a . ., . z � . q ; , R ' y' � _ �� ' . ¢ ,�.:a '1 . i , ,r ✓� � � 5i e a« � J �" l �y��r, t'.�+�?�^�''i ? � �•� ta)"'�,�?�L �'�,`�it . �..i�sae t ;r �', _ I � • "�t ��•"` t,� ► �t �'�� ir 'L = . � '. � " �ia. � - � � � :iY� .C.. K�� 14µ�,. �'�,` ?� ;�. 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APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (33�753-6780/Fax(336)751-8786 ' Application For: ❑ Site Evaluation/Improvement Permit ❑Authorization To Construct(ATC) ❑ Both Type of Application: �New System ORepair to Existing System ❑Expansion/Modification of�xisting System or Facility **�`IMPORTANT"`**THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed s Contact Person Billing Address Home Phone �q � - l�y(��, City/State/ZIP ' �usiuees�l�one +�4,�9 C�il T- Name on Permit/ATC if D�erent than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facili Corners Fla ed NOTE: A survey plat or site plan must accompany this application. Included: � Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name t� Phone Number � 0 Owner's Address S ' 1 City/State/Zip_�a��u; � � ]�(�.� h ��' Property Address City��,k S y; ))e Lot Size i..sl � y �, T PIN# Subdivision Name(if applicable) Section/Lot# Directions To Site:"� ° • _ � � � � If answer to any of th following questions is"yes",sup orting documentation must be attached. Are there any existing wastewater systems on the site? �(('Yes ❑No Does the site contain jurisdictional wetlands? ❑Yes�QNo Are there any easements or right-of-ways on the site? OYes ONo Is the site subject to approval by another public agency? ❑Yes�No Will wastewater other than domestic sewage be generated? ❑Yes o IF RESIDENCE FILL OUT TI�BOX BELOW #People #Bedrooms �_ #Bathrooms � Garden Tub/Whirlpool ❑Yes f�Vo Basement: �Yes ❑No Basement Plumbing: ❑Yes o �� IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness 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: QtConventional ❑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? Thic ie tn ePrtifv that thP infnrmatinn nrnvir�PA nn thic annlicatinn ic trnP anri rnrrPct tn thr ha�t nf mv lrnnwle�iaP T nnriPrctanA that \ • r . � • ' �� DAVIE COUNTY HEALTH DEPARTMENT � ' .• •- � � ' Environmental Health Section Soil/Site Evaluation � APPLI NT NFO MATION ��Z�'�RTY INFORMATION Account #: 99 005740 Tax PW/EH#: 5853-a Billed To: Het n Myers Subdivision Infa Reference Name: Location/Address: 4607 Spillman pa -27028 Proposed Facility: Re idential Property Size: 1.754 Date Evaluated: 2� Water Supply: On-Site Well Community Public Evaluation By: Auger Boring � Pit Cut FACTO S 1 2 ' 3 ' 4 � 5 6 7 Landsca e osition Slope% o HORIZON I DEPTH �j— Texture grou S � �, � -,..., _._ . Consistence Structure _ ;�;.,,� Mineralo ; . '� ` �_ HORIZON II DEPTH '.20 Texture rou C Consistence - Structure Mineralo Q ' HORIZON III DEPTH Texture rou . Consistence Structure Mineralo HORIZON IV DEPTH Texture rou � Consistence Structure Mineralo � � ' ' SOIL WETNESS RESTRICTIVE HORIZ N - , � - SAPROLITE CLASSIFICATION LONG-TERM�ACCEPT CE RATE SITE CLASSIFICATIO �S EVALUATION BY: b� LONG-TERM ACCEPT CE RATE: • Z2� OTHER(S)PRESENT: 1/ REMARKS: . LEGEND " 7,andsc,ape Positi n , R-Ridge S -Should r � L-Linear slope FS -Foot slope N-Nose slope CC-Concave slope V-Convex slope T-Terrace FP-Flood plain H-Head slope � � . S -Sand LS -Loam 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 (:ONSI4TF.N . , NI�iS� .., VFR-Very friable -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 plasdc �tructure SC-Single grain. M Massive CR-Crumb GR-Granulaz ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineraloev � 1:1,2:1,Mixed L�� Horizon-depth-In inches ' Depth of fill-In inches Restrictive horizon-Thic ness and inches from land surface . Saprolite-S(suitable),U( nsuitable) Soil wetness -Inches fro 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) � T TAR _T.nnv-tr.rrn ac�Pnt nra ratP_ aal/rla��/ft7 Tnrm nc�nc in--•:--��