361 Michaels Road Lot 35- - DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 989900024 Tax PIN/EH #: 5746-20-3132
Billed To: Roger Spillman Subdivision Info: Sallie Acres Lot # 35
Reference Name: Roger Spillman Location/Address: Michaels Road -27028
Proposed Facility: Residence Property Size: 1.5 Acres
ATC Number: 2193
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a 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 A t�j #People #Bedrooms _ #Baths 2
Dishwasher: ET' Garbage Disposal: ❑ Washing Machine: 0� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size ,% 81 L Type Water Supply (�b— Design Wastewater Flow (GPD) Site: New Repair ❑
System Specifications: Tank Size GAL. Pump Tank
Other:
Required Site Modifications/Conditions:
GAL. Trench Width .,� Rock Depth//Linear Fts,� ed
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.****
r
Gi
Environmental Health Specialist's Signature: Date:
DCHD 05/99 (Revised)
--
Account #:
989900024
Billed To:
Roger Spillman
Reference Name:
Roger Spillman
Proposed Facility:
Residence
ATC Number: 2193
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Tax PIN/EH #: 5746-20-3132
Subdivision Info: Sallie Acres Lot # 35
Location/Address: Michaels Road -27028
Property Size: 1.5 Acres
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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: A�Zav- Date:
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 ArticleY1 qG.S. Chapter 130A, Section .1900 "Sewage Treatment and
Disposal Systems," but shall in NO WAY t en as a guarantee that the system will function satisfactorily for any
given period of time.
llyb 1 ltle yrs 6 n S' 7
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
)d 0 z°RC4,
Date:
PddgLON FOR SITE EVALUATION/IMPROVEMENT PERMIT &
d Davie County Health Department Q .
Envim menia/Health SeWon
w� P.O. Box 848/210 Hospital street
Mocksville, NC 27028 APR 2 9 1999 rr
(336) 751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS n
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed �6 J I r , ' Contact Person
A
Hailing Address Some Phone -
City/State/ZIP `ty / V ���V Business Phone / R
,Y
2. Name on Permit/ATC if Different than Above a!
Hailing Address City/State/Zip i
3. Application For: L1 Site Evaluation ❑ Improvement Permit/ATC OZBoth
6. System to Service: ❑ House Mobile Home 0 Business ❑ Industry 0 Other
5. If Residence: # People _ # Bedrooms— # Bathrooms
�1 Dishwasher 0 Garbage Disposal Washing Machine 0 Basement/Plumbing 0 Basement/No Plumbing
6. If Business/Industry/Other: Specify type # People # Sinks
# Conmodes # showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated hater Usage (gallons per day)
7. Type of water supply: County/City ❑?Nell ❑ Com ounity
e. Do you Anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No
U yes, what type?
-***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
!�,-operty 2'.rejaioab� /-S & �/-
Tax Office PIN: #: Sj 7% U
Property Address: Road Name AtGhoub /c -c--'
City/Zip i_ l.&1i& Z70 21
If in a Subdivision provide information, as follows:
Name: 5 (X"
Section: Block: Lot:
WRITE DM CTIONS (from Mocksville) to PROPERTY:
m 1 d)t. /E
Ldf 9 tf- zS
Date Property Flagged:' 17
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
issued hereafter are subject to suspension or revocation, if the site pians or intended use change, or if the information
submitted in this application is falsified or changed. I, also, understand that I amr nsible for l charges mcuffed from
this application. I, bereby, give consent to the Authorized Representative of the D ' CountyH4 h rtment
to enter upon above described property located in Davie County and owne b.'
to conduct
//all testing procedures as necessary to determine the site suita
�s r &A
DATE T' Z 9' 9 I SIGNATURE 14 12
1
THIS AMA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include(I of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Revised DCHD (07/98)
Account No. 62,2— z1
Invoice No. / 0.?
-' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION---./—LOTZ
Soil/Site Evaluation
APPLICANT'S NAME //'7 fit J DATE EVALUATED
PROPOSED FACILITY PROPERTY SIZE
SUBDIVISION TS� /r � ROAD NAME W';
Water Supply: On -Site Well Community / Public 4_�
Evaluation By: Auger Boring Pit ✓ Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
Sloe %
7
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture groupL-
Consistence
Structure
Mineralogy
A
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
o
SITE CLASSIFICATION:
EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
REMARKS:
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 (01.90)
i
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NO
ON
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SELENE MENNEN MMiiiiiEMNON No
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60 3i4"EIP N 10°37'20"E N 10°44'15"E 249.11' Total N 10°52'20"E
t 109.08' 100.00' 100.00' o
CCe Bu dag �e pOj a
.zI•
rni'I t (�
UziIN
i
+37y
c
Chairman, County Plonnin �9`
140' Building '-'ne
,3.66' 72.34' 87.17'
100.00' 100.00'
I 100.00'
S 07 07 10 K 159.51'
Total S 10°44' 15"W
318.83' Total
Total
(20' gravel)
� O
60 3i4"EIP N 10°37'20"E N 10°44'15"E 249.11' Total N 10°52'20"E
t 109.08' 100.00' 100.00' o
CCe Bu dag �e pOj a
0148'05 E 8 4
;I
n n
4 j zvO
W
� r
O to
a,
N
n25
!*01'05"E
t ; 200.09'
u,)
'n
i ip N
o
rn �
Zi a
`� , 3 53 44"27' 00"x,
20.23'
" 3i4 EIP�
- --� 3/4 E.�F,�ent}
-T
�3 6
Uri
M
I
04
?� o 1- - ( „
4 ?9 O M o ¢40 '�7•
4S'7y of c 4) \\� k
W'
bi
N
NOTES:
1) Zoning: R—A
2) Water shed
3) Ail lots to 1:
4) All utilities t`;
5) All lots shall
6) All lots to h:
7) Tota! subdivi;
8) All k'ts shall
9) Average lot
10) No USGS m
11)36 Lots ins
Tax L
Tax M
Sr
OJPNzR.-
0.r'z
.r -
U)
U) X49 \ Developer:
1 Roa
Tax Lot 2F P Totoi P.
SJ �e
'ax Map M -5-7 ��' o
Coo
n -'f
C'cuae R. ern _r lax Lot 18 I ! /2 "EIP
Tax Map M-5 Fh,Q
.r 94 0 PG 5'0 /
Glenn Foster
DB 114 ® PG 773 p(%r'
.; ee
Wd'
l i SCALE TOWN
` 1 _ 100' 'eru5
JUL 17 OWN
SURVEYED: Stone
CRS
ENVIRONMENTAL HEALTH MAPPED:
DAVIE COUNTY
S
c
0OY
<
O
� O
O�
i O
Z
z
'(2It
2>'=
�—.
' ,2J)
,n
0148'05 E 8 4
;I
n n
4 j zvO
W
� r
O to
a,
N
n25
!*01'05"E
t ; 200.09'
u,)
'n
i ip N
o
rn �
Zi a
`� , 3 53 44"27' 00"x,
20.23'
" 3i4 EIP�
- --� 3/4 E.�F,�ent}
-T
�3 6
Uri
M
I
04
?� o 1- - ( „
4 ?9 O M o ¢40 '�7•
4S'7y of c 4) \\� k
W'
bi
N
NOTES:
1) Zoning: R—A
2) Water shed
3) Ail lots to 1:
4) All utilities t`;
5) All lots shall
6) All lots to h:
7) Tota! subdivi;
8) All k'ts shall
9) Average lot
10) No USGS m
11)36 Lots ins
Tax L
Tax M
Sr
OJPNzR.-
0.r'z
.r -
U)
U) X49 \ Developer:
1 Roa
Tax Lot 2F P Totoi P.
SJ �e
'ax Map M -5-7 ��' o
Coo
n -'f
C'cuae R. ern _r lax Lot 18 I ! /2 "EIP
Tax Map M-5 Fh,Q
.r 94 0 PG 5'0 /
Glenn Foster
DB 114 ® PG 773 p(%r'
.; ee
Wd'
l i SCALE TOWN
` 1 _ 100' 'eru5
JUL 17 OWN
SURVEYED: Stone
CRS
ENVIRONMENTAL HEALTH MAPPED:
DAVIE COUNTY
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT a
` APPLIC .�
Davie County Health Department �rnp
Environmental Health Section JUL 1V
P. O. Box 848
Mocksville, NC 27028 ENVIRONhlEtITALNFhlt11
(704) 634-8760 pAV1E COUPITY
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed Contact Person
Mailing Address POI (JAY —739 Home Phone )Al- 2-7 07
PIL
City/State/Zip (�O lam( mj"t / Ol Business Phone 20 / -) 5+ I
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: ❑ Site Evaluation EV" Improvement Permit & ATC ❑ Both
4. System to Serve: ❑ House Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms # Bathrooms 2—
U"'Dishwasher ❑ Garbage Disposal Mr Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Other:
# Commodes
If Foodservice:
7. Type of water supply:
Specify type
# Showers
# Seats /
9R County/City
# People # Sinks
# Urinals
Estimated Water Usage (gallons per day)
❑ Well
# Water Coolers
8. Do you anticipate additions or expansions of the facility this system is intended to serve?
If yes, what type?
❑ Community
❑ Yes UNo
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: b-701 q6' —4 -WRITE
DIRECTIONS (from
-
Tax Office PIN: # _ _ _ - ��
I Mocksville) TO PROPERTY:
1 O /
lyv�
v/��
Property Address: Road Name
� ag
tel/ ,,
1 14t c� lG(�/A
�-/
ko( o'
/'� J
City/Zip ' / 6; i ! oZ D.2
If in Subdivision provide information, as follows:
i w P n
0),L/ f
Name:
Lot #:
Section:
✓� 1
1
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter
are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is
falsified or changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to
the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County
and owned by a YK to conduct all testing procedures
41 -
as.-
as necessary to determine the site suitability.
DATE -7 ' 4, 93 SIGNATURE
Revised DCHD (06-96)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER
Davie County Health Department
Environmental Health Section YY
l/r W P. O. Box 665
/ Mocksville, NC 27028 EAUH
1. Application/Permit Requested By ` o;7a��_Ser";ce C ejartilic
Mailing Address �_'? ' t ��`r"`� f �. AR n Home Phone 6 �`/ 39:33
; j�d�, //�� Business Phone u sZ `Js
2. Name on Permit if Different than Above
3. Application for: / General Evaluation ❑ Septic Tank Installation Permit
4. System to Serve: ®'House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown j
5. If house, mobile home: Subdivision — —� ,T o"a' GJQ� Section _� Lot # .L!
D
,AA_ 2 1 1995
.17 ❑ Basement/Plumbing
No. of People
No. of Bedrooms
No. of Bathrooms F*
Dwelling Dimensions J0L
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Sinks
No. of Urinals
No. of Water Coolers
No. of Showers Water Usage Figures.
7. Type of water supply:ublic ❑ Private
8. Property Dimensions ,/0 Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
If yes, what type?
❑ Basement/No Plumbing
❑ Washing Machine
❑Dishwasher
❑ .Garbage Disposal
❑ Yes 9�4o
❑ Community
'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property:
�,q/ sa:A Igo
S .�
This is to certify that the information provided is correct to the best of my knowledge,
incurred m this application. �
N ✓JQ5
DATE
I understand I am responsible for all charges
SIGNATURE`
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED OROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representativp,.of the D9, . Co�lnry Health Qepartment to enter upon above described
property located in Davie County and owned by tfoii eh, } 4eeyi'ce . Thr• .
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
!Ay,�'s
DATE
DCHD (1 193)
DAVIE COUNTY HEALTH DEPARTMENT3S
Environmental Health Section
Soil/Site Evaluation
NAME
ADDRESS
PROPOSED FACIILTYo��t'�
Water Supply: On -Site Well
DATE EVALUATED���
PROPERTY SIZE ZA
LOCATION OF SITE
Community
Public
Evaluation By: Auger Boring Pit t Cut
FACTORS
1 2 3 4
Landscape position
4,
Sloe Z
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
Mineralogy/./
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
,
SITE CLASSIFICATION: // EVALUATED BY:
LONG-TERM ACCF,P)TkNCE RATE: - .. ) OTHER(S) PRESENT:
REMARKS: jr=:nN goy /A/) N 'r 61 C'' `
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 -:lay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR- Vl---y 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
3C --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/fU
DCHD(01-901