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898 Spillman Rd , DAVIE COUNTY HEALTH DEPARTMENT ` -� ' Environmental Health Section /���_�v _ � Z_ ' ; . �' P.O.Boa 848/210 Hospital Street Mocksville,NC 270Z8 (336)751-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 990002344 Tax PIN/EH#: 5853-28-6181 Billed To: Aletha Segal Subdivision Info: Reference Name: Location/Address: 898 Spillman Road-27028 . Proposed Facility: Residence Property Size: see map ATC Number: 3192 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALJTHORIZATION 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 THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type � #People � #Bedrooms f #Baths � Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑ � Commercial Specification: Facility Type #People ' #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply c�/ Design Wastewater Flow(GPD)� Site: New� Repair❑ System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width��Rock Depth�/Linear Ft.� Other: Required Site Modifications/Conditions: INIPROVEMENT/OPERAT[ON PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF 6"BELOW FINISHED CRADE. ****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(33G)751-87G0.**** ! Environmental Health Specialist's Signature: e 7 Date: �'�(�� DCHD OS/99(Revised) . , . .� DAVIE COUNTY HEALTH DEPARTMENT � � Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (33G)751-8760 Account #: 990002344 Tax PIN/EH#: 5853-28-6181 Billed To: Aletha Segal Subdivision info: Reference Name: Location/Address: 898 Spillman Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3192 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MiJST BE ISSUED 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.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWAT� CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: ' Date: �"�� 2 CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation 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. �� 1f�d� ���"�r��2 � Septic System Installed By: Environmental Health Specialist's Signature: ,��/y!/►� _ Date: f/�- 7 ` �v DCHD OS/99(Revised) r , . s . ,, ' APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&AT D � � /� - Davie County Health Department � C� Q I)� Environmenia/Hea/th Sect�ion V � P.O. Box 848/210 Hospital Street ' t/(�N . . Mock�336)751N87607028 �_ .. 2 8 200Z �Ro,�r�t � ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE � INFOF2MATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instruction . 1. Name to be Billed 1 QG{ G!� S Contact Person ��� � �S � Mailing Address 1���" Home Phone `�.��p "' ��� '�3 2 3� City/3tatejZIP �/"!q` �O/n f'i n�l� �, /Z�R ./ Business Phone 3 3(O ��d`p ` ��,3 Q T1 2. Name on Permit/ATC iP Different than Above Mailing Address City/State/Zip 3. Application For: �ite Evaluation ❑ Improvement Persnit/ATC �11'Both f 4. system to service: ❑ House ❑ Mobile Home ❑ Business ❑ Industry � ther CQ i i�- / �/ID 7�' y�u n C�` 5. If Residence: # People ,S # Bedrooms � # Bafhrooms/ I ❑ Dish�rasher ❑ Garbaqe Disposal ❑ Washing Machine O Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Sndustry/Other: Specify type . -' • #"People # Sinks . . .. _ . . # Commodes - # Showers � � # Vrinals • # Water Coolers _.. ,. _ � . ,, , . _ IF FOODSERVICE: -#,Seats ': ._`.. . Esta.mated Water Usa e _ . �J (5allons per day) � 7. Typa of water supply: ❑ County/City �Well ❑ Community s, Do you anticipate additions or expansions of the facility this system is intended to scrve? ❑ Ycs �o If yes,what type? ***IMPORTANT*'�*CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUES'I'GD BELOW. Either a PLAT or S1TE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. ; t Property Dimensions: � , O � QGrC S WRITE DIREC'TIONS(from Mocksville)to PROPLRTY: TaxOfficePlN: # �0 5.� Z��P � � ' � �S'Qe Q�QGh Po� <fe�-�<z-�'v�� �9 $ � Property Address: Road Name r / p c�tyiz�p o�ks v�JI e, NC : 27a28 If in a Subdivision providc information,as follows: Name: Section: Block: Lot: Date Property Flagged: �,�/�5'l/.1-7 S ('�! G��e. � This is to certify that the information provided is correct to the best of my knowledge. 1 understand that any permit(s) issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or if the informution submitted in this application is falsified or changed. I,a1so,understa»d tliat I am responsible for a!!cl:arges inct�rred froni tlris application. I,hereby,give consent to the Authorized Representative of the Davie County Hcalth Departmcnt to enter upon above described property located in Davie County and owncd by A l e�ti Q Ss� c—K S �i q� to conduct all testing procedures as necessary to determine the site suitability. DATE � U� 2 SIGNATURE G?,.vf� THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the foilow� g: Existing and proposed property lines and dimensions, structures, setbacks, aad septic locations). � . Q��,� Site Revisit Charge 1 � U Datc(s): : Client Notification Date: EHS: ' Account No. �� 7� Revised DCHD(07/99) Invoice 1�1a `" / � � AREA= 55.87� INCLUDES S.R 1458 a �. �� P .2�1 . � k� p�~ � . . � Z 532.2 22 S 86'Ol' �•jP <TIE) '_�29� E�.a _ � i � �� � // r ♦� �/ J� �. '`�'`�'co � o --L �� �� �� ' � � 4 g � � '� . , o� ii �O� ,• � om /� 60 J� �� ,� Z2��b ,,y.�>> 2 �� S y0 a � �" �� � �A ,, Y� � ii �o��,L g5. , CREeK �/ , ��� � ' I/ ��a,ENs // '�� � N 15'SO'38' H�� `� F.`P � / 35,93 `°�;� �t 4� �� ?p N E�►M�N�ME � ,�• y �, E.i.i // ��u� N 76',�� o �. 2Z �o o:� p ►noNUMEnT � �'� � E.I.P 287.72 � E.I.P 167.98 E.f.P 408.15 E.I.P E�P ' � �--- N 88•51'OS' Y N 88'38'S2' V s- S 88'07'S5' Y 59,p fi /Y ,�•� 5�.,� y S.R. >458 so. - R/yf, SPI.LLM�N��RD. � � I�.B, 155 �.EST . .: ti �9 �,B, �7 ' PG 33g . . , , .. �,��Sm �,B. '8�, P�, 333 00 , P , 144 � E.I.P � �� -�. �` � �' �� Z � ,��y8YG8fOg�� I, GRADY L. 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'� - • ` . • • DAVIE COUNTY HEALTH DEPART'MENT - ' ry Environmental Health Section Soil/Site EvaluaHon APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002344 Tax PIN/EH#: 5853-28-6181 Billed To: Aletha Segal Subdivision Info: Reference Name: Location/Address: 898 Spillman Road-27028 Proposed Facility: Residence Properry Size: see map Date Evaluated: "7 -/�fl.2 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 - L Slo e% HORIZON I DEPTH Texture rou Consistence Structure Mineralo - HORIZON II DEPTH �� Texture rou Consistence Structure Mineralo � ` HORIZON III DEPTH Texture rou Consistence Swcture Mineralo � HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE . L - ' SITE CLASSIFICATION: EVALUATION BY: _ LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: LEGEND � Landscape Position R-Ridge S-Shoulder L-Lineaz slope FS-Foot slope N-Nose slope CC-Concave slope . CV-Convex slope T-Tenace 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-Subangular 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 DCHD OS/99(Revised) 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