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995 Spillman Rd . DAVIE COUNTY ENVIRONMENTAL HEALTH . ' ' � � j P.O.Box 848/210 Hospital Street ' � � Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 . AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990003799 Tax PIN/EH #: 5843--96-7636 Billed To: John &Kathryn Brehm ' Subdivision Info�G�1��'' , Reference Name: Location/Address: Spillman Road-270�8 Proposed Facility: Residence Property Size: 14.084 acres ATC Number: 4565 Site Type:�New ❑Repair OExpansion **NOTE**This Authorization to Construct(ATC�MLTST BE ISSIJED by the Davie County Environmental Health Section prior to issuance of any building petmit(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 FIVE YEARS. This ATC is subject to revocation if site plans,plat or ��v the irnended use chan e. g ��1��01 �t►�_ � �T��� � � � � /11�� Residential S cation:Buildin h �Flo #P le #Bedrooms #Batbs Basement w/Plumbing:✓Basement/No Plumbing,_,_ Commercial Specification:Facility Type #People #People/Shift #Seats � Lot Size Type Water Supply pesign Wastewater Flow(GPD) Site:New Repair System Speci.fications:Tank Size f o��GAL.Pump Tank_GAL.Trench Widih 3 Trench Depth 3G." Rock Depth�'_Linear Ft '�/$D , �s stated�in 15N A�CaC 98.�.1�3�i3d5� Other: �,r��,7Fd ��ystEm� rnay a�Su b� �►.sEa �� �� Required Site Modifications/Conditions: e Contact the Davie County Environmental Health Section for final inspecHon of this system between !�� 8:30–9:30a.m.on the da of installation. Tele hone# 33 751-8760. `�i�f ���s�b5� . • wz�l — -- `� �«c� ./ f--- — — — �. / l � � i5p' .� � / � ��Lh� Hvw,� � �'c�ctcic,l,,�� • r_ .��. ' �tvf+�.X.o� ����¢. j� �`-c.tiG�� �C) Y!`e f/i S��'���PC� 06� X a ��,� kj_ri� L Q '•/� ���� , rGri"SbuP�9rur��r Y1L� ���c���' �7�cr�w � �`��Y,�• j;' � �, �• ` �p ` 'k'��'�_�. 3CP p„�1 N o n.�s r t �l�n t[r,w �k s�., �l,G -�. ��Q�� � p O� �!'r, �` Y(-'c�C�9� ��Gw�� Iu�S��cr.L�.ec�' �*.� n .� • . °hcr. ��yk oa 5-(0��� o�� �a4.ii6J1P �to . ��Co6kc����e yc�-�u-�,a f e��! �dZ � �j f�"{- �t f�e.uk S�to.t�c� � ��.C 5 e: ���QLp . .i�.7 ��e..�`'r . . Environmental Health Specialist � Date: �'-1 Z �� DCHD 11/06(Revised) . I b\\'I P. ('OI�\ll' II�'VIRONMEN'I'AL III?AI:I'I I . . , ���, . • P.O. Itos S�l�C 210 Hospital Strect >,���;,,;u�,�c z�ozs a�g�a� �:_�i�,i-s��o r�. ::�z�b»>i-s�sc, ����rnoKv.���rio�� Fo�i�vAsrr:��.a�rr:a svs�re�� co�s�rii�c�r��m� Account #: 990003799 Tax PIN/EH #: 5843--96-7636 Billed To: John & Kathryn Brehm Subdivision Info: Reference Name: Location/Address: Spillman Road-27028 Proposed Facility: Residence Property Size: 14.084 acres ATC Number: 4565 tiitz l)pc: ��\c�c Rcpair F.xpansion ••NOTE"`This Authorvaiion to Conslruct(ATC) MUST BE ISSUED by the Davie County Environmen�al Health Sec[ion prior to issuance oCany building perntit(s), (in compliance a�th Ar[icle I1 of G.S. Chapter 130A i Wastewater Systems. Section .I9W Sewage Trcalment and Disposal Systems). THIS AiTI'HORIZATION TO CONSTRUCT IS VALID FOR A PERIOD FIVE YEARS. 7ltis ATC is subject to revocaaon if site plans, plat or ihe intcnded use change ��/G� ��� rvl �2l Q��h Residen�ial Specifcation: BuildingTtipejr 4io,t,� #People ` #Bedrooms - #B.uhs_ �` ��e V Basemen[�v/Plwnbing:._Basement/No Plumbing_ Commercial Spccification:Facility Type #People #Peoplc/Shift #Seats L,ot Size Typc Watcr Supply Dcsign Wastewatcr Flow(GPD) Site: New_Rcpair_ Spstem Specifications: Tank Sv.e I�GAL. Pump Tank_GAL. Trench Width 3 Trench Depth �t, ' ` Rock Depth �� Linear Ft. Y$G' h� �5 ���tea in 15N �GFC 78;.156';r!5) � Oth¢[ . �d �v�ten= �r.av +Is � <:t�d � �`�� Rcquircd Site Modifications/Conditions: �c Contact the Davie County Emironmental He•rlth Section tor final inspection of this system between �� R:311—9:30am.on the dav af installa[ion. Tele hone#(336)751-876U. 'iJ 4�...��b+` — — --- -- --- — „� � `�t, ��c j � • — — — — — — — - � i / �Sp ' � � / � i.,tik ^ Hvµ» �ei�afel< ys� . � Or�,� �j,.r�_'• / n � • � �.c. c�5 1J �p�e tn5��� �I.ar GN ')' � Q kj'r�:� � I 1 y� �' �� r3'r�� �GI1�I�uf��/YUc�r 1aOC'«�/�e.� l�+cw i' ./�2 Y i•`j:- " � �p�9' �}3�.�-= �j�r•� (ync� NO N-..� 'Skr. f(vw �4w.. �L � rOo���r,. 'F T���tl„Ps -�hcwlc� ��51u11..�1 a� �'o ° ha� � ' � a��•. �U�e ��' �yk pn 5/cNr o'> P @CCOtkt'c�[��< �1l.y�a� c j tL1[��:: Cif! / �` �i ;�'f- �tle.+ck5Ga�1.1 �-j � ,- c sP: �ks�i �ti F�� Enviromnental Hcallh Specialist ��s ' v Date: l —l � �� DCHD I I/OG (Rc��iscd) - — i DAV�COUNTY ENVIRONMENTA,L HEALTH � P.O.Box 848/210 Hospital Street . • • �, .' Mocksville,NC 27028 (336)751-$76Q Fax#(336)751-8786 OPERATION PERMIT P ���{. , _ _ �. � � Account #: 990003799 � �� � Tax PIf�UEH :#��84 6-7636 Billed To: John 8�Kathryn Brehm/��I���ubdivision Info: _ ` � _ � — � Referen�ee Name: Locatio . piffman Road-2702a Proposed Facility: Residence � Property Size: 14.084 acres . /. // ATC Number: 4565 **NOTE**The issu�lce of ihis Ope�r�a on Permit shall indicate the system descn'bed on the ATC bas been installed in compliance with Anc�le 11 of G,B.Chapter 130A, Section.1900"Sewage Treatment and Disposal Systems," but shall in NO WAY be taken�guarantee that the system will functian satisfactorily for any given period of time. CQ r� ��5'� � / ` �� � r System Type• /�"' /S.T.Manufacturer Tank Date C�' �3�r�s�� ( OG� Pump Tank ize � �/ c �D System I ed By: �{ � � ''�'��E.H. Specialist: Q�� Yls Date: � � � r � J , E �C..�� po�c G� � _ (4° p � � ��,�� t � 1�,� , 3S �, ;� �� � _�-� �s.� , .� � �o � P.,�r►.;,� , .�6 w-a�� ;, n, � � � r,� �� �� _ �� . . . DCHD 11/06(Revised) • i .. � 1�I� SITE EVALUATION/IMPROVEMENT PERMIT & ATC ` � 00,� Davie County Environmental Health � 2 P.O.Box 848/210 Hospital Street �A� � � Mocksville,NC 27028 �jP��� (336)751=8760/Fax(336)751-8786 aaN�`. o�� � � Ap lication 1�� valuation/Improvement Permit [�YAuthorization To Construct(ATC) ❑ Both Typ of A ion: ONew System ❑Repair to Ezisting System ❑Expansion/Modification of Existing System or Facility • � ***IMPORTAN7***THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed���-+� M � �1�T�n'l� $�NM Contact Person � � �rt 1�7�L1�1M Billing Address l S g � U P1,A-��. Home Phone 33�0 `i�18 q 53�- City/State/ZIP ��v�C� C. 'L'�o o�o Business Phone 33(� �-1� Za�i� Name on PermidATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged � $ ��'7 NOTE: A survey plat or site plan must accompany this application. Included: O Site Plan ❑Plat(to scale) (Permit is v�lid for 60 months with site plan,no expiration with complete plat.) Owner's Name�n� �� �P-"��[+� g'R��1�'� Phone Number33� ''q 9 ����3 Owner's Address ��Fb �6U2�0 P(AP�v City/State/Zip�A1v� t.t�-� Z"I oo So Property Address �Y�t�-MA.r-� RD City !�OC��g�l t�e� Lot Size ��- �.Gp-��j Tax PIN# �g Q-�-q(c�`7��3(0 Subdivision Name(if a plicable) Section/Lot# Directions To Site: �����• o►� '��lti1.iC1turQ R� - �oa SP1U�M�MJ ) sTc�cc- o F pplJ���r If the answer to any of the following questions is"yes",supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes L�No Does the site contain jurisdictional wetlands? ❑Yes 6�No Are there any easements or right-of-ways on the site? ❑Yes �No Is the site subject to approval by another public agency? ❑Yes'�'No Will wastewater other than domestic sewage be generated? ❑Yes o � �4 IF RESIDENCE FILL OUT THE BOX BELOW ��� g #People #Bedrooms #Bathrooms Garden Tub/Whirlpool ❑Yes �No Basement: Yes ❑No Basement Plumbing: es ❑No 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 systemrequested: �onventional ❑Accepted ❑Innovative �Alternative ❑Other Water Supply Type: ❑ County/City Water �1ew 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? This is to certify that the information provided on this application is true and correct to the best of my lmowledge. I understand that any pe 't(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the info ation submitted in this application is falsified or changed I hereby grant right of entry to the Authorized Representative of the Dav Co ty Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understan tha I a re onsible for the proper i entification and labeling of properiy lines and corners and locating and flagging or staking c' i ation,pro well location and the location of any other amenities. . Site Revisit Charge � pe owner's or owner's legal representative signature � ,� Date(s): Client Notification Date: Date EHS: Sign given ❑Yes �No � Account# �� Revised 11/06 Invoice# _1� � .�_ �. .(� '. � , � ` �1PP IC�l7lUN FOR SI7C CVALUATIO�V/lhiPli0llLhtCM PLR�titIT - ' � � � u U � (� '�J" r ., Davie County Health Department 1-� ��. PnvironmentalHealthSection ��� Z .2 ZQt��J � G P.O. Box 848/210 Hospital Street MOcksvilla, NC 27028 � ' j� h � �t (336)751-0760 E1�MMRONMENTAL�HEAITH ;' �Q�, � . , , DAVIECOUNiY .w�, U' " ��� ***I�IPORTANT*** TIiI� APPLICATION CANNOT �E PROC.GS�SED UNLESS ALL TFi� R1:QUIR�D INFORt•L7�TION IS PROVID�D_. Refer to the INFOR2SATION BULLET22d for ina�ructionB. T � '.� � 1. T7ame Lo bc Dilled���(�f-a � � �}���'k'�=�� ���-��'�'�onEact Per�on ����`� ���'�M 1•Sailinc� Addro�n ��T> �`-^�l�lu�T 3 t� Itome Phono ��cU —�"1 � �L���-- CiCy/Stato/ZIP /x�V j u"✓�i 1V�i Z�vC� IIu�inenn Phono ��� �� � -`"�Z 2 2. Namo on Permit/I�TC if Different than 7lbova 24aili�ic� Addrou� C�ty/Statn/Zip � ]. Applicstion For: � SiLc �va3uation ❑ Improvement Permit/ATC ❑ Doth a. syacem ro sarvice: •�IIouDe ❑ 22obile Home ❑ Iluuine33 " ❑ Induntry ❑ Other i � 5. Typo nyatem roque�tod: � Conventional ❑ conventional modified ❑ innovativo l�lac�epted 1 6. Ii- -Itesidenca: U Peoplc � 8 I3cdrooms t► DaL-2irooina �� �Di�hwa�hcr ❑Garbago Diaposal �i4ashing Machina L�Aasement/Plun�ing ❑Uaoemen�/17o Plumbing / 7. IL Dunineuu/Induatry /Othor: verify type � Peoplc 1t Sink� A Commodon II Showora 1F Urinala It 1•laCnr Coolarn IF FOODSERVICE: �� Seatu Estimated Water Ut�age (gallonn per dayl 0. Typc of vratar aupply: � County/City �T'Tell ❑ Community �. Do fou anticipato adcliCions or cxpansions of il�c L•icilitp ti�is sys(cm is intc»dcd (o scrvc'? ❑1'cs �No II�•cs, titi•t�at typc? y ""*'`L7IPORT'i11Y7"'**CLILNTSAlUSTCOdIYLETETII� RL•QUIItL•D PROPCR'TY INI�ORl9AT10N RLQULS'TLll fi1;i.O1V, rithcr a PI.AT orSITC PLA�I 4fU.ST IlESU11AfIT?T•A bv tl�c clicnt �vilh'i'IIIS APPI,ICATION. 1'ro �crt}•1)iuicnsions• ��+ ��`T ��� NIt1T�DIIiECI'IOnS(frum 11�Iocics��illc)to I'Ii01'LRTI':' 'I':ix OfGcc I'Il`t: �� �����'� �'L'7'�D ��J"�L3 � ' �F'I�'r!'Jvlc�►G�T��.S. i'3> � •— Proper(y rtddress: Road Namc ✓1?�LL NV��-1 �f'—� LY�� <�� Sf'lLh,1`�'Y.�'�- '� �'�L� c,�y�z;n �c��i�sy��c,� NL Z�02� �A-�� •,����,zr�l� �=� ICin a Subdi��isioit pruvidc iiifoi•riiatio�i,:ts f lolvs: �����—ti�� ��'�' ��'� �C'►�'�� ' __� � rr:►,nc: � S10'� Scclion: 131ock: Lof: Datc homc corncrs Ilaggcd: �� � �� '1'liis is (u ccr(ifj•tl�al llic inCorc»atiou providcd is corrcct to tlic bcst of niy l.no�vlcdgc. I undcrsl�ncl llint any perinit(s) issucd l�crc:iflcr are subjcct (o suspcnsion or rcvocation,if thc sitc plans or intcndcd usc cl�angc,or iC tlic informalion subniil(cd in lhis application is i�IsiGcd or changcd. I,nlso,rurdcrslairrl drut I rr�rt respousrLlc for all cicurgcs i�lcru•r•crl jran tlris af�plicaliv�r. I, hcrcby,Uivc conscut to thc Autl�orizcc] Rcprescnfati�•c of tlic a��ic Cow�t �IIcal(li Dcparhucut (o ct�lcr i�p�n abovc dcscribcd pi•opci•t)'localcd i�i llavic County and oti�'nc y � ���U�� GC:I�'�'�,�' to conduct all tcsting pr ccclin�cs as�icccssar��lo dcicriniuc tlic sifc suitabilil �. . DA7'I: �� �7 �� SIGI�ItI'1'URL TIIIS AKL;A 111AY B�USLD rOR DI2�L1'��ING YOUR Sl'TI;PLAN(Includc:�I!oI tl�c follotirinb: L�isting aud proposccl propci-ty lincs and dimettsious, siructures, setbacics, and septic locations). � . Sitc Itcvisit Cl�argc � . Da tc(s): ' � � ���1 ( ��,y Clicnt Notification Datc: � �/ �I�IS: �- d'� �Y`�� / V �c" � � 7� Sign�ivcn !t?� �, '• wAccowtt No. .� �o� ��� Rc��iscd llCIIll(05/03 Im•oicc No. � _ _ � � ���c- �-- � a. - °o Pq p� $j/I ��k L " D.B. ����.sp�l.Ld(qN y�� D B. 03 pc�lZ � ���� � °�, �'* .,,� �• a. +� �BFY����*'s "�'"` . r�-� � �, . � ���, ✓� � M �� � �1��. 0{��._ '�+��' s' �` r '� � 'Y` � o d��'I i� � ar •ao�q•re �d� ��` fiA= �4.084 AC. ��` `4at � /s�d;CD� � , ia �w� .A S�� ��+ p�r � y ��26y�ASJ ���1' '� � � � i oi'�o"r�w-�'r r„e��a�i ��1-�.SI/l_7 u s aasx�i rsn �, . -�'�� �---' ��-�,C�� ,� q: "3-�r� '� .� ��.�•„ �. �K.,,�„ ,�a � � � � .� � � ss f� • ' e�a= e.sss ac. ,� ,,� ` NCl�SA IISi R�w �a ��"�� f0 6[OOI/VOrm TO 1tYif 110rOt5 �, g e . k �'4`��� 1r ky�y � a a�, «�. � F �! � Y� b, ��,` �O� �ly y a�� . . �o—Y�p uV y ~�� S�1Y� �� 4 m3� �4�°'Y�r =�sfiC v � '�r ra�a•v O 'Y'm O1f *�+= ARdA� 4.665 d C. . i— w�a uai.oes sa ttsa�/y � r��s.vr v n �p" •���*� m et mmcr�u ro w¢*c:� . •F_— � ��,1r / _ � • :' � ��� �i�t�+r.� . ., � •;:.� '. � DAVIE COUNTY HEALTH DEPARTMENT • ' � • Environmental Health Section " Soil/Site Evaluation � APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003799 Tax PIN/EH#: 5843-39-2576 JB Billed To: John&Kathryn Brehm Subdivision Info: �. �o � Reference Name: Location/Address: Spillman Road-27028 Proposed Facility: Residence Property Size: 14.084 acres Date Evaluated: /2��'d� > Water Supply: On-Site Well v Community Public Evaluation By: Auger Boring Pit Cut FAC'TOR5 1 2 3 4 5 6 7 Landsca e sition Slope% �, HORIZON I DEPTH (o '� ( Texture rou GL d`C � Consistence �- (/t� Structure ,�p�- �— Mineralo - / , HORIZON II DEPTH �' L 8 r) Texture rou Consistence T Structure / f% Mineralo _% HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou � Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE , (- SITE CLASSIFICATION: ' G � 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-Terrace FP-Flood plain� H-Head slope T�ut�rs � . 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 .nN4IS .N . Mois VFR-Very friable FR-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 plastic �� SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralo�v � 1:1,2:1,Mixed Notes Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thiclrness 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/OS(Revised) ■�����■����■�����■��■■�■�■■��■��■���������■�����■■e���■�■���■����■ ■�■■�����■■■�■�■�■�■�■����■����■ ■■���■■�■■�■��■��■■�s���■■�■�■�■ ■�■■�����■����■■�■�■�■�■■�■■�����io���■■■■��■��■���■�■��■���■�■��■ 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' ' : i ��� � D��k�II� CC�UN`TY`���.T�;.���'��T1��iT..�,,.�,�,,..�.,����� � �. � �. Environmental Heaith Section P. 0. Box 848/210 Hospital Street Courier 09-40-06 Mocksville, NC 27028 336 751-8760 '��� �� ( ) � � December 9,2005 John&Kathryn Brehm 188 Woodburn Pl. - Advance,NC 27006 Re: Site Evaluation/ Spillman Road 2 sites Tax Office PIN: #5843-93-2576 Dear Client(s): As requested, a representative from our office visited the aforementioned sites on December 8,2005. Based on the information provided on the Application for Site Evaluation and after an evaluation was completed on the sites,they were found to be provisionally suitable for the installation of on-site sewage systems. Before and ImprovementJAuthorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions,please feel free to contact this office. Sincerely, fa�t cB��,/��,' Robert B. Hall,Jr.,R.S. Environmental Health Specialist RBH/dlf • . DAVIE COUNTY HEALTH DEPARTMENT • " = ' Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INES?RMATION I'I�� � ��� � � �'►'�v� �l��►�. y �i e � , � '�( �� � �.��. . 5 � �� 3 -3�i ����� � Water Supply: On-Site Well v Community Public ? � ��^d� Evaluation By: Auger Boring / Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca sition Lt LL Slo % HORIZON I DEPT'H �� 6- Texture rou G c Consistence Structure � Mineralo ` � ; • HORIZON II DEPTH ��,-"l - Texture rou G Consistence Structure � '" -4'A4ti Mineralo � �:� . HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo - SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFTCATION LONG-TERM ACCEPTANCE RATE � o•� � SITE CLASSIFICATION: �:7 ui�u y� ~ EVALUATION BY: i LONG-TERM ACCEPTANCE RATE: •� OTHER(S)PRESENT: _. ., REMARKS• ,. LEGEND I, n s e Position : ` • R-Ridge S-Shoulder L-Lineaz.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 . .ONSIST .NC , ; �'�41St � VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm '}5.�' .� ' , , � NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky; NP-Non plastic SP-Slightly plastic P-Plastic VP-Very'plastic ' �YLIi�� _ , SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic ; Mineralo�v " 1:1,2:1,Mixed 1YQtr� Horizon depth-In inches - Depth of fill-In inches Restrictive horizon-Thickness and inches fmm 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-gallday/ft2 . DCHD OS/OS(Revised) ; • Davie County Environmental Health . ' : P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (33�751,8760/Faa(33�751-8786 IlVIPROVEMENT PERNIIT Account #: 990003799 Tax PIN/EH#: 5843-39-2576 JB Billed To: John &Kathryn Brehm Subdivision Info: Address: 188 Woodburn Place , LocationlAddress: Spillman Road-27028 City: Advance Property Size: 14.084 acres Reference Name: Proposed Facility: Residence **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Corrstruct 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 11 of G.S.Chapter 130A,Wastewater Systems). Ttus Improvement Permit is subject to revocation if site plans,plat or the intended use change. Permit Type: L�1ew �Repair �Expansion Permit Valid for: �5 Years ❑No Expiration Residential Specitications: #Bedrooms ' �3 #Bathrooms 3 #People�_Basement�Basement plumbing0 Non-Re.cidentiat Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): 3 (a0 Type of Water Supply: ❑County/City �,Well �Community Well As stated in 15A f�C�:C 18f..196Q(5j . Site Modifications/Permit Conditions: ��cepz�d Systems may alsc� b;: t.asEcl S em e LTAR �niaat a , - R � Ck� s O�a site Plaa /+; P°,,���a �1 �S �-oc a�c� o � 'I b�'f'`e- � -�-_"•� . � �� �� ` �_ � / �� � ��—���:.a.t w u� ^�'`{p lj��( �t� �Q��O�� dt^�k`� Y ' 6,, '�� . �a� �� 6� ��`�� � �bv�e ��";� �/ ����� G��. \ � u.. � ,� �c-� _ . �. �_ \� j � \ �-�.��f-ca rn-c _ �- � — Environmental Health Specialist � -- -Date /-/Z'0 7 i.p.l 1-06 `. �„ .. , ta, .. . .. -- .. ��i�' �' ' �. . .KESI��ENT�4L w�i.t,corisritv�oi� .. .. ��.]`� . � North Carolina lleparhnent oflinvironm�nt and Natural K.a"�oat�es-Ilivision of Water Quslity • Y . . '�1�..1 w ... . . � ••...V..,...• ' wEi.i,corrrxncroR cER�c��ii�iv� ��.� l� . 1. CONT CTOR: � • • L DISINFECTION:Type �H Amount� S 1��/ .��r!'cr� ���+�n� a w zor�s�ae Well Cor�tracUor(I n d i v i dua q Name • From,�,To� From To Yad]cin Wel.l Compariy, II1C. From ' To From To Well Conttador Coi�any Name • From To From To STREET ADDRES3 1908 Hamptonville Road s. casmu3: Thickness/ � Depth� p%S r ��/ � t ['iai Hamptonville NC ' 27020 � From�_To R(e. City or Town State Zip Code From To R. 3c 36 �. 468—�440 . Frorr� ro FtL Area code- Phone number • • 2.VYELL INFORMA710W � � T. GROIIf: Depth Mated I Method ' ,� Frort���To 3 R. p°���►�� SITEWELLID#pTappticable) ��' � l(� From_j To�_R C.1Nl+E'+c �Uw� • STATE WELL PERMIT�(if appticable� • FrorrL To Ft. DWQ or OTHER PERMff#(if app6cable) 8. SCREEN: Depth Diameber� Slot 5[ze Material VYELL USE(Check Applicable Box): Residentfal Water Suppy j� From To Ft in. in. `1 � From � To Ft. tn. in. DA7EDRILLED !ot -�� "O� From To R. in. tn. TIME COMPLETED �� �� 9. SAND/GRAVEL PACK• 3.WELL LOCATION: ' Depth � S¢e Mffiedal . CITY: �C.�►3 �`L 4(/G�COUN7Y � From To Ft From To Ft � � /°j� Nc�r� �� ' � From To F't. (Street ame,N ers,Commtu�t�jl, uS bdivts os►,Lot No.,Parcel,Zip Code) . TOPOGRAPHIC/IAND SE7TING: 10.DRILLING LOG • _ �bPe ovai�ey pFlat ❑Rid9e pott►er • From To Formation Description c�neac ePwnr�t��� D --5v �'�.� �y��a��, � LATITUDE 3 ;� � m;�„��� SO '— 7O �c�'C.�L_ LONGITUDE�� ��. -L'vS m°docmulfotmat 70`o7�/a 'eyc� �--- Latitude/longitude sow�ce: pGPS p�'opograptric map (hcafion of weB mus!be show»on a USG8 lopo map and . aitached to�Is furm�not usdr�g GPS) . 4.WELL OWNER ��j n . OWNER'S NAME_�C►Iv!�V��, �`t . STREET ADDRESS " City or Tw�m State . Zip Code �_�_ ��}- �arial Np, Giz[� c�ff � Area code- Phone number • • 11. REMARICS: • 6.YVELL DETAIL.S: � r a. TOTAL DEPTH� Q • b. DOES VYELL RE1PlACE EXISTING WELL? YES p NO� • � 'I DO NEREBY CEKiiFYTHAT'ilit3 W ELL WAS CONSfRUCiED IN ACCORDANCE WRN c. WATER LEVEL BelowTop of Casing: C, FZ'. �an rrcac zc,wEu corisrnucnori srnwoazns.AND7HATA COPY OF 7HIS . (Use'+'�AboveTopafCasine) R ow�semr�rtaivoEOTo'rt�w��owNat. d. TOP OF CASINCi IS � . FT.Above Land Sudece' �%'1 P/!?1Y)�.�U✓ ��1�'u"'���'�/a��'-��'� . `Top of casing terminated aUor below land surfece rtmy require SIGNATURE OF CERTIFlED W ELL CONTRACT R DATE a variance in e�ccbrdance wHh 15A NCH�C 2C.0118. / e.�YIELD(9Pm):_�Q�_____M�}iOD OF TEST �r P�P !`.f-s?�f7"h� �a�l�� G/��lh»+rr� PRINTED NAME OF PERSON CONSTRUCTING THE WELL Submlt the original to the Division of Water Quality within 30 days. Attn:Intortnatlon Mgt, F�,,,Gw-�a 1817 Mall Servtce Center–Ralelph,NC 27698-1617 Phone No.(819)733 7018 ext 568. • Rev.7105 Date site visited --Z —Q y erct�it - � Yes N� • f?a%��� r� ���'J����G�et�' .� . 3..440�-d'G S� ' ' `� 4� -fZ �oo