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.
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1f�d�
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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 `"
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� AREA= 55.87�
INCLUDES S.R 1458
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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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