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255 Nolley Rd Lot 19 & 24 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ©� P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: .989900024 Tax PIN/EH#: 5735-49.8688— Billed To: Stacee Wyrick Subdivision Info: Wildwood Lot# 19&24 Reference Name: Location/Address: 2.55 Nolley Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3601 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of septic tank system or any wastewater system. An AUTHORIZATION 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 IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type ]AL)" #People_ #Bedrooms 3 #Baths Z Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size^'] AUt Type Water Supply C604TY Design Wastewater Flow(GPD) :Z11DO Site: New Repair❑ System Specifications: Tank SizelOCC)GAL. Pump Tank GAL. Trench Width—74--o Rock Depth I Z Linear Ft. :3Cd Other: 3 DisTQAv-:-,oTf>— Required Site Modifications/Conditions: c-),) C >. 14 V4DEP S CFF 00 eAE, V-ED� 1 o 00P W. L,49 IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this 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(336)751-8760.**** Sr o&-roaAL- Sot��rvo PILL- t LA S -� Z" i Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) 012-710 z T t DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 `j zzs Account #: 989900024 Tax PIN/EH#: 5735-49-te6e— Billed To: Stacee Wyrick Subdivision Info: Wildwood Lot# 19&24 Reference Name: Location/Address: 2$5 Nolley Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3601 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATE NS U IS V D FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature ate: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. 'lac Septic System Installed By Q LD 3? Environmental Health Specialist's Signa e: ate: I 3 �O DCHD 05/99(Revised) 10/20/2003 14:50 3362846188 SPILLMANS PAGE 01 + APPUCATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Davie County Health DepUtimlit EmllivnfixnW Mooft SbCdbff P.O. Box 848/210 Hospital Street Mookoville, HC 27028 (336)7518760 rrrZ"p0R=h-"** THIS ApPLIChTIOU CMtT r B!DNOC==UTAESS ALL THE IRLD INlOMMION IS PROVIDED. Refer to thhe{�IN1'ORt+li1TION BULt.ETIN for ins nons, 1. Mom to I-Died � l COmteCt PereOm smelling hddreee Po j$V X 3 8'. _ mom Man* City/l4t6/iIP r!]_D�b�„�LtL �1L �7aly V*.v,... at,.s. 413 no/ Z. Umm m PGRAWATc AS DAtteaemt the,abere w.tlAaa Add:... city/srata/&Lp a. Application "V: 0 Bite tivalur►tion 0 Isprovamant Pa-4 t/ATC .al Both .. aysten to setvAmz 0 House t3iltobile Homo O Business 0 Iadnetry C Other'1 3. Zr Residence: 1 people ( a Bedrooms -3 s Rai=oms U DA.hsseber n tarbage Disyosal Maw O ss.omat/PIwabAay a sm mamt/ma Pl-mUmho . S. If sue}nes■/sndu.tsy/Other: specify type P.ap1a H "nka # commodes 1 anowess s Urinals •mater coolave IP FOODSERVICE. i) Seats Estimated Nater Usage 19aiLon.Per ) 7. Type of water supply: --i�County/Cit:y O Nell 0 coreunity S. Do you anticipate sddidom or expausions of the bellity this system Is intended to serve? Yes U No Ryes,what type? rr*]AfPORTAN7v**CUEMM=CVAfFLEMTIIE)tEI21,7X DPItOPERTYINFORMATIO HEQUMED BELOW. EitheraFLAT orSITEPLAN NUSTNESUB)WT=0 thecut.t withTHISAPPUCAI ION. Property Dimensioss: WRITE DIRECTIONS(from Moehsvill)to PROPERTI': f Tax 0111ce PIN..Q,-& OU�O 6q 03 l� (00%5 -v cn 0 G i � Rd Propttty Address: Read Name oZ3!5-t V 1 d O t p1mro.tim Cl"., ClC d1 �St %29 Q�- drti 'No i If I4 a Subdivision provide information,as follows: Av� �2��•Naasc• GSection: Block: Eat: 9� DataPropert Afteds-This is to certify that the information Provided is correct to tthe best of pry knowledge. I Understandissued herca)tee are subject to suspension or revocation,if the site Plans or intended use chaste,or submitted 11 this application is falsilled or dwaged I,alsv,uxifiMand t4at J om twpowiblc for ap cba es Ihcaned from Ibis application. 1.hereby,give consent to the Authorized Representative of the Davie Cao Health D artment to enter upon above described prop"located is Davis County and owned by to conduct all testing procedures as accessary to determine the site suis DATE 1 d —19-03 SIGNATURE THIS ARIA MAYBE USED FOR DRAWING YOUR SITE PLAN(Iaclade an opt the f9aawiaE: Bsistt g and propend Property Rues and dimesslons,stractarsx, setbacks,sad septic Iocatioss). Site Ravi,t Charge Date(s): ti Client Notification Account No._ a Q�� 4 Revised DCHD(a7/99) invoke No t) T C/ ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SoiVSite Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900024 Tax PIN/EH#: 5735-49-8666— 18"8 g Billed To: Roger Spillman Subdivision Info: Wildwood Lot# 19&24 Reference Name: Location/Address: 2,f5 Nolley Road-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: �� tZ, 0;2,- Water 3Water Supply: On-Site Well Community / Public ✓ Evaluation By: Auger Boring d11`, Pit V Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope% HORIZON I DEPTH - Texture group LL Consistence SS Structure Mineralogy HORIZON 11 DEPTH - 2101 Texture group Consistence ; Structure Mineralogy HORIZON III DEPTH .y 2_q6 ( Texture group C,� Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: QS EVALUATION BY: � LONG-TERM ACCEPTANCE RATE: t OTHER(S)PRESENT: REMARKS: �OM� �.CY`.� i'I{y Sor,&E c-i LL -#-1kz4 4&A�D? 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 Mineralogy 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-gal/day/ft2 DCHD 05/99(Revised) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■s■■■■■/■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■casae■■■■■■■■■■■■■/■e■■■■■1�■■■■■■/■■■■■■■■■■■/■■■■■e■/■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■e■■■■■■■■e■■■■e■�■■e■■■e■■■■■■■■■■eeee■e■e■e■eee■■■e■■eeee■e■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■:Ila■■ee■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ENCiiiiiiiiiiiiiiiiiMENNEN ■■■e■■■■■■■■■■■■■■e■■■■■e■■!tl■■■!!�3►'■e■■ell■■ee■■■■■e■■■e■■■■ee■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■►yes==e�:====c;.::i■■■■■■■■■■■■■■■■■■■■■■■■■■ ■e■■■e■■■■e■e■■e■■■etc■t■►■■e■■■■w■■■ee■eee■■■■e■■■■■■■■■■■■■■■■■■■ ■■s■■■■■■■■■■■■■■■■■e■■e■■►�e■■e■ee■■ee■■ee■■■e■■ee■ee■■■e■eeeeeee■ ■■e■■■■■■ee■■e■■■e■■eee■■■■■■■■■e■■■■■■e■■e■ee■■■e■■ee■■■■■■e/e■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ 10/20/2003 15:35 3362846188 SPILLMANS PAGE 02 _ • Ile or 16 A lb Y 1 T • ? 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