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929 Spillman Rd -' DAVIE COUNTY HEALTH DEPARTMENT : „ � ' Environmental Health Section b-3 �`� �4 ' ' P.O.Boz 848/Z10 Hospital Street � � �k�' �' Mocksville, NC 27028 y � � (336)7S 1-87C►0 IMPROVEMENT/OPERATION PERMIT Account #: 990002599 Tax PIN/EH#: 5853-16-0021 Billed To: Merry Ana Holcomb Subdivision Info: Reference Name: Location/Address: Spillman Road-27028 Proposed Facility: Residence Properry Size: 5+acres **NOTE�*�is�mprovem�ndOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALTTHORIZATION 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 PERNIIT LS SUBJECT TO REVOCATION IF STTE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type ��� #People � #Bedrooms�_ #Baths �.5 Dishwasher: C''r Garbage Disposal: � Washing Machine: � Basement w/Plumbing:� BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � Lot Size �p3�-� Type Water Supply�El1- Design Wastewater Flow(GPD) �� Site: New� Repair❑ '� �� � System Specifications: Tank Size���GAL. Pump Tank GAL. Trench Width�' Rock Depth IZ- Linear Ft.� o�h�: Z`��szR��T�o�, g�, l�SrAL� u►��s q'o.c. �,� . Required Site Modifications/Conditions: ���'rAI.L C� �'iDi1�, � �S � c,k�=`P �0���- We�.�.- IN[PROVElF1ENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6 G°BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Depaztment for final inspection ofthis system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 130 p.m.on the installation. Telephone#is(33G)751-87G0.**** �Y�c� �1���''�1 ��x Ico' '��� l � cr �F�� L1��S � �t t� o�� SP�u�e.� R�o�� � '1� <[ Z � . -�'n�a-� � � 3$(Z ���,�`�� �—�,j� �M����^o�` � M�� ` � � . 12��x.3t."�c..i 2,,� . Y�j� ��r . H �j Environmental Health Specialist�Toi�:aocii oi � � Date: � � I DCHD OS/99(Revised) ' � � � + � • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ��� P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990002599 � Tax PIN/EH#: 5853-16-0021 Billed To: Merry Ana Holcomb Subdivision info: Reference Name: Location/Address: Spillman Road-27028 Proposed Facility: Residence Property Size: 5+ acres ATC Number: 3450 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** T'his Authorization for Wastewater System Construction MUST 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 WASTE S IS ALID FOR A PERIOD OF FI YEARS. Environmental Health Specialist's Signa e: Date: CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion 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. ��'�1► Ta�k- �4�.� �� � -� , ; � - �, S �a sT � ro �{�t� C�nr�S ��o �a �-�- I� iZa x. �'���-�` Septic System Installed By: � �-� Environmental Health Specialist's Signature: Date: � � DCHD OS/99(Revised) :� . �- ��:�� +� ` ' y�, o J 2d�---- - - ; ,, ' � (ra � � � � CATION FOR S17E EVALUATION/IMPROVEMEM"PERF��IT&I�T� /, `� Z d c��� D r �`------ � Davie County Health Department � �^'''� � Environmenta/Hea/th Section � /w�� — I ,��B � � ?f;!13 P.O. Box 848/210 Hospital Street E , Mocksville, NC 27028 � '2 3 S �� i � (336)751-8760 - L'`-- �M� EN�LA HFAL�H ', ���/� � � *** S APPLICATION CAIVNOT BE PROGESSED UNLESS ALI, THE REQUIRED , ORI�TION IS PROVIDED. Refer to the INFORI�,TION BULLETIN for instructions. 1. Name to be Billed `r I Contact Person ���.�'�h'�Islx-C:G'/!wJ + Mailinq Address �a� V�� �Q(J� Home Phone " "�`�S '�"ld� City/State/ZIP � �Q�j'�/N» �/ 1� ����� Business Phone ��a 'y pW �' Name on Pezmit/ATC if Different than Above ��L-` --/�eQ a'��� � � � �`�j / ` � Mailing Address CitY/State Zip '�..� �_ � � �v3 -•,3. Application For�Site Evaluation � Improvement Permi.t/ATC ❑ Both \ . 4. System to Service: C�House � Mobile Home p Business ❑ Industry � Other ► 5. If Residence: � � p People � g Bedrooms _� � Bathrooms �� IZ � ; �i( Dishxasher C�Gazbage Disposal �1 Washing Machine L�Basement/Plumbing ❑ Basement/No Plumbing . . kj .� ,. . .. . . 6. xf susinass/inans txy/Other: SpecifY type / People # Sinks - A Commodes M Shoxers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage �gallons per aay) 7. ,Z�pe of.water supply: ❑ County/City �Well ❑ Community . e: Do you anticipate additions or cxpansions of t6c facility this systcm is intended to scrvc? �Yes ❑No . If yes,what tyPe7 .S.UI,"� Y G� �"��-('1',ct� �11 GCQ�� , ***IMPORTAIYT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW.: Either a PLAT or SiTE PLAN MUST BESUBMI7TED by the client with THIS APPLICATION. 4 Property Dimensions: h�a�' ,T WRITE DIRECI'IOIVS(from]Yiocksvillc)to PROPGRTY: Tax Office PIN:� #-_- -,.��'s53'1(eOL�`� I zlb E �t� g�l -' �� �d I Property Address: Road Name ��1 I)YY10�1'1 kC� �� ���I�YY�'7�,�'� (Z(� a . city�z�p �n"1Yxa►'l�� �nrnnon�Fu 4Y1 �- —,� If in a Subdivision provide information,as follows: Name: Section: Biock: Lot: Date Property Flagged: � � �� � �_ ' . T6is is to certify that the informatioa provided is correct to the best of my knowledge. I understand that any permit(s) issued 6ereafter are subject to suspensioa or revocation,if the site plans or intended use change,or if the information submitted in this application is falsified or changed I,also,understa�rd t/iat I am respoirsible jor n/!drarges inct�rred f�o1�r this application. I,hereby,give consent to the Authori7ed Representative of the Davie County Hcalth Department to enter upon above described property located in Davie County and owned�y to conduct all testing procedures as necessary to determine the site suitability. DATE_ o'��3'D� SIGNATURE • THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN( clude all of thc foltowing: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge ��c � / Date(s): (� J � U�-� Clicnt Notification Date: � �jS �Lz� pr. 6V1. �(� �' EHS: �� a �-/ �3 � - ° " �O �9 � Account No. -� Revised DCHD(07/99) ����-w'y`' � Invoice No. , S � � �,� e_f.�./ � /,��-�-- ��� , � � �S'S� ,/ � �', l ,p'`"'°�`` /n� , � \ � ?�J I .� , �, (��ggJ \�� , � �� 923 0 ,. �_ �288) � 302 � SPILLMAN ROAD �� �; (745) ( I� -- (272) / , -� '� ti�_ � ��, � , � ��� ,� k.;50000nQ810'Y" ��c i F`°� �� �;N � A � � � ,�� (5.03�A) � - -- � -- - 0021 / 3934 379 � ���� --' � � w Q � � � � . DAVIE GOUNTY HEALTH DEPARTMENT.,,-,_ ; ' � Environmentai Health Section � .Soil/Site EvaluaHoi� APPLICANT INFORMATION �. �.<;� PROPERTY INFORMATION .' ' , � ' . . �. . c r ;R'� { . . .. � Account #: 990002599 . � : T�z;QIN/EH#: 5853-16-0021 Billed To: Merry Ana Holcomb , Subdivision,(nfo: . ' . � . ,��� .. .T. . . Reference Name: � �• ~ ;� LocationlA:ddress:. Spillman Road-270 8 � 1, Proposed Facility: Residence : Property Size: � 5+acres . Date Evaluated: 2 a ,,» _ �� r . �i,= Water Supply: On-Site Well Community Public � , Evaluation By: . Auger Boring Pit �• Cut .-.: ,�<> - ,,r, FACTORS 1 , 2 3. 4 5 6 7 Landsca e osition � °l L L. Slo % . G,� . � HORIZON I DEPTH (� - � p - � . Texture rou C�- .L Consistence r S ; ' i Structure _ _ S 1� • Mineralo 1� 1 1 i HORIZON II DEPTH : 22. � Texture rou i Consistence � ; ,S •/� 5tructure . ' � � Mineralo �� � I= HORIZON III DEPTH 2� 'L(,- Texture rou � Consistence - • Structure � � Mineralo . MI d • HORIZON IV DEPTH Texwre rou � � Consistence � `" Structure . Mineralo sou,wETrrEss . . N . RESTRICTIVE HORIZON SAPROLITE ..�-�.-': � CLASSIFIC�TION~": � S LONG-TERM ACCEPTANCE RA 0• � � . SITE CLASSIFICATION: > EVALUATION BY: ��-� �� P � LONG-TERM•ACCEPTANCE RATE: O•� OTHER(S)PRESENT: . REMARKS: 6�T1:�L V�.-�Tf l,��JC7 3C,,� � �'�I bt Afj� . � �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='Subangular blocky PL-Platy PR-Prismatic Mineralogv 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) � ■��■���■ev�■�■�■���■o�■■■�����■es■���■�■■��■��■o����■■������■�s�■■ ■e�s�■v��e���■■■�s��■■��■������■�a�e����■���������■��■��������a��■ ■�■��v�■�o�e�■�■����e�■�■����■�■��■���������■�■■�■��■��■�����s■�■ e�■��■v�����a�■■���������■��■��■ ■■■����■������a�■�����■������■�■ ■�■�����■��■��■�■������■�■■�■�■��■��■■������a���o��■����■������■■■ ■����o■�����■�■�■�eo���o�o■�������■���o■����■��������������������■ 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E d8 7 : �'� � ,� r' ff� �rH �. d t � � � 3'� € E ", �� E.��.a� ��'�t,�J�•a`� �a y /��� � /i � � ' ��� +�r�'en'c. < < E � ' �r h�- �' w �, �� � ...,. , �;, � � r ,. _ : �.d��'4 �� -�` - �r /�/ jj � t ���" .� �E[��EW � �»,� � �� �� ��� , ����� ��� .:�� � j� ' ��' �' � �' .... � .,�.. �r�s{ fis�'���� ..k� i/���.�;; i �i N��.,.,.:: �.,..�.� �� � , ,. � , �,_ ,.,, " . , ,��'�. ry !.\�`2S\. /iuMwuwuwwwin �' .,. E� �E J fY 1�,t. .. ��&e»ii..,.ia ,: .. > ..:.� .. . :...... ... . . . .• DAVIE COUNTY HEALTH DEPARTMENT . Environmental Health Section � . P:O. Box 848/210 Hospital Street Mocksville,NC 27028 Phone: (336) 751-8760/Fax: (336) 751-8786 February 6, 2003 Merry Ana Holcomb 8271 Dull Road Clemmons,NC 27012 Re: Site Evaluation- 5.03 Acre Tract/Spillman Road Tax PIN#: 5853-16-0021 Dear Ms. Holcomb: As requested, a representative from this office visited the above site February 6, 2003 to perform a site evaluation. Based on the information provided on the Application for Site Evaluation and after the evalua.tion was completed,the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. It should be noted that a pump station will be required based on the staked house location. Before a representative of this office will revisit the site to issue an Improvement Permit/Authorization to Construct,the appropriate application must be completed in full and submitted to this office. The location of the facility the system is to serve must be staked off. '� - - If you have any questions, feel free to contact this office at 751-8760. Sincerely, / . Jeff G. Beauchamp, R.S. � Environmental Health Section Enc(s)