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438 Michaels Road Lot 20Davie County, NC Tax Parcel Report Tuesday, December 20, 2016 WARNING: THIS IS NOT A SURVEY ParcelInformation Parcel Number: M502OA0020 A Township: Jerusalem NCPIN Number: 5745196340 Municipality: Account Number: ` 82519941 Census Tract: 37059-807 Listed Owner 1: - SAWS LP Voting Precinct: COOLEEMEE Mailing Address 1: PO BOX 738 Planning Jurisdiction: Davie County City: COOLEEMEE Zoning Class: DAVIE COUNTY R -A State: Zoning Overlay: DAVIE COUNTY CZOD Zip Code: 014-0000 Voluntary Ag. District: No Legal Description: LOT 20 SALLIE ACRES Fire Response District: JERUSALEM Assessed Acreage: 0.72 Elementary School Zone: COOLEEMEE Deed Date: 122002 Middle School Zone: SOUTH DAVIE Deed Book / Page: 004560826 Soil Types: GnB2,CeB2 Plat Book: 0006 Flood Zone: Plat Page: 160 Watershed Overlay: DAVIE COUNTY Building Value Outbuilding & Extra Freatures Value: Land Value: Total Market Value: Total Assessed Value: 161 Davie County, (�County N`-' All data Is provided as Is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the Implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the of Davie, North Carolina, Its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out of the use or Inability to use the GIS data provided by this website. OPERATION PERMIT P„ Davie County Health Department �- 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Roger Spillman Address: PO Box 738 City: Cooleemee State/Zip: NC 27014. Phone #: (336)'284-2551 *CDP File Number 193988-2 M5-020-Ao-020-A County ID Number: Evaluated For. REPAIR � Township; rproperty owner: Roger Spillman Address: PO Box 738 City:Cooleemee State2ip: NC Phone #: (336) 284-2551 27014 Property Location & Site Information _ Address/Road #: Subdivision: Sallie Acres Phase: Lot: 20 438 Michaels Road Mocksville NC 27028 Directions structure:' MOBILE HOME " Hwy, 601 S. right on Hwy 801 right on Michaels Rd # of Bedrooms: 3 # of People: *Water Supply: PUBLIC *IP Issued by. *CA issued by: 2140 - Nations, Robert Design Flow: 3 6 0 Soil Application Rate: 0 - 3 'System Classification/Description: TYPE III G. OTHER NON -CONN. TRENCH SYSTEMS SaproliteSystem? OYes eNo 'Distribution Type: GRAVITY -SERIAL Pump Required? OYes JE)No 'Pre -Treatment. Drain field Nitrification Field - 11 a 0 0 Sq. ft. No. Drain Lines 3 Total Trench Length: 3 0 0 ft. Trench Spacing: 9 Inches O.C. Feet O.C. Trench Width: _ 3 Olnches Feet Aggregate Depth: inches 'System Type: INFILTRATOR QUICK 4 STANDARD Installer: William D Wyrick Certification #: 2676 'EH S: 2140 -Nations. Robert Date: 1 0/ 2 7/ 2 0 1 6 Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. 2 4Inches Approval Status Maximum Trench Depth: 3 6 Inches I FIF41'Approved[3 Disapproved Maximum Soil Cover: 2 4 Inches CDP File Number 193988 - 2 Manufacturer. Shoat STB: 760 Gallons: 1000 County ID Number: M5-020-Ao-020=a septic -T-anK Lat. Date: is 8/ 0 6/ a 0 1 6 *Filter Brand: POLYLOK Dual PL -122 With Pipe Adapter ST Marker: ❑ Yes 2 No nforced Tank: ❑ Yes 0 No 1 Piece Tank: ❑ Yes [B NO Manufacturer. PT: Gallons: Long: Installer: William D Wyrick Certification #: 2676 *EH S: 2140 - Nations, Robert Date: 1 0/ a 7 / a D 1 6 Approval Status,. ® Approved ❑ Disapproved - Pump Tank Pipe Size: inch diameter Pipe Length: feet *Schedule: Pressure Rated ❑ Yes ❑ No Lpproved fittings ❑ Yes ❑ No Installer. Certification #: *EH S: Date: Date: I I Approval Status O Approved❑ Disapproved . Pump Type: Installer. Dosing Volume: - Gal Certification #: Draw Down: Inches *EHS: *Chain: Date: Date: I I Valves Accessible ❑ Yes ❑ RiserSealed ❑ Yes ❑ No No RiserHeght: ❑Yes Check -valve ❑ Yes D No (Min:6 in.) Reinforced Tank: ❑ Yes ❑ No 1Piece _Tank: „❑-Yes .__. ❑ No----. No No Pipe Size: inch diameter Pipe Length: feet *Schedule: Pressure Rated ❑ Yes ❑ No Lpproved fittings ❑ Yes ❑ No Installer. Certification #: *EH S: Date: Date: I I Approval Status O Approved❑ Disapproved . Pump Type: Installer. Dosing Volume: - Gal Certification #: Draw Down: Inches *EHS: *Chain: Date: I I Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check -valve ❑ Yes ❑ No Approval Status PVC Unions El Yes ❑ No El Approved ❑ Disapproved Vent Hole ❑ Yes Anti -siphon Hole ❑ Yes ❑ ❑ No No A. - CDP File Number 193988-2 ` County ID Number: m"20-Aa020-A Alarm Audible ❑ Yes Alarm Visible ❑ Yes Approval Status C] Approved ❑ Disapproved 2140 • Nations, Robert _._._._'Operation Permit_ completed by: Authorized State Age n . - Date of Issue: 1 0 / a 7 / a 0 1 6 _. Owner/Applicant Signature: This system has been installed in compliance with applicable NC General Statutes: Article 11, Chapter 130A, Rules for Sewage Treatment and Disposal, 15A NCAC 18A .1900 of, Seq., and all conditions of the Improvement Permit and Construction Authorization. This, property is served by a TYPE III G. sewage septic system. Rule .1961 requires that a Type -TYPE III G. septic system meet the following criteria: Minimum System _Review.ByThe Local Health Department: NIA Management Entity. OWNER Minimum System Inspection/Maintenance Frequency By Certified Operator: N/A Reporting Frequency By Certified Operator: NIA Rule .1961 requires that a Type IV and V septic systems designed for a home/business owner must maintain a valid contract with a public management entity with a certified operator or a private certified operator for the life of the septic system. Rule .1961 requires that Type VI septic systems designed fora home/business owner must maintain a valid contract with a public management entity with a certified operator for the life of the septic system. - Rule. 1961 (2) (e) requires a contract shall be executed between the system owner and a management entity prior to the issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the system owner and certified operator are the same. The contract shall require specific requirements for maintenance and operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long as the system is in use, and other requirements for the continued proper performance of the system. It shall also be a condtion of the Operation Permit that subsequent owners of the systems execute such a contract. @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Electnc Equipment NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer: Box 12 inches Above Grade ❑ Yes ❑ No Certification #: Box Adj. To Pump Tank ❑ Yes ❑ N o Conduit Sealed ❑ Yes ❑ No 'EHS: Pump Manually Operable ❑ Yes ❑ No "Activation Method: Date: Alarm Audible ❑ Yes Alarm Visible ❑ Yes Approval Status C] Approved ❑ Disapproved 2140 • Nations, Robert _._._._'Operation Permit_ completed by: Authorized State Age n . - Date of Issue: 1 0 / a 7 / a 0 1 6 _. Owner/Applicant Signature: This system has been installed in compliance with applicable NC General Statutes: Article 11, Chapter 130A, Rules for Sewage Treatment and Disposal, 15A NCAC 18A .1900 of, Seq., and all conditions of the Improvement Permit and Construction Authorization. This, property is served by a TYPE III G. sewage septic system. Rule .1961 requires that a Type -TYPE III G. septic system meet the following criteria: Minimum System _Review.ByThe Local Health Department: NIA Management Entity. OWNER Minimum System Inspection/Maintenance Frequency By Certified Operator: N/A Reporting Frequency By Certified Operator: NIA Rule .1961 requires that a Type IV and V septic systems designed for a home/business owner must maintain a valid contract with a public management entity with a certified operator or a private certified operator for the life of the septic system. Rule .1961 requires that Type VI septic systems designed fora home/business owner must maintain a valid contract with a public management entity with a certified operator for the life of the septic system. - Rule. 1961 (2) (e) requires a contract shall be executed between the system owner and a management entity prior to the issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the system owner and certified operator are the same. The contract shall require specific requirements for maintenance and operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long as the system is in use, and other requirements for the continued proper performance of the system. It shall also be a condtion of the Operation Permit that subsequent owners of the systems execute such a contract. @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC Drawing Drawing Type: Operation Permit • .06 CDP File Number: 193988 - 2 County File Number: MS -020 -AO -020-A 27028 Date: / Olnch Scale: , OBlock W ft ON/A Applicant: Address: City: State2ip: Phone #: • t' CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 / For Office Use Onlv 'CDPFileNumber 193988-2 County ID Number: M5 020 -AO -020-A Evaluated For. REPAIR �, Township: Phone: 336-753-6780 Fax: 336-753-1680 0 8/ 1 0/ a 0 a 1 Roger Spillman PO Box 738 Cooleemee NC 27014 Property Owner: Roger Spillman Address: PO Box 738 City: Cooleemee StatelZip: NC 27014 (336) 284-2551 % phone #: (336) 284-2551 Property Location & Site Information r Address/Road #: 438 Michaels Road Mocksville NC 27028 Structure: MOBILE HOME # of Bedrooms: 3 # of People: "Water Supply: PUBLIC Subdivision: Sallie Acres Phase: Lot: 20 Directions Hwy 601 S. right on Hwy 801 right on Michaels Rd Site Classification: Provisionally suitable Saprolite System? QYes QNo Design Flow: 3 6 0 Minimum Trench Depth: Inches Minimum Soil Cover. Inches Maximum Trench Depth: Inches Soil Application Rate. 0 3 Maximum Soil Cover: Inches 'System Classification/Description: 'Distribution Type: GRAVITY -SERIAL TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: Gallons 'Proposed System: 25% REDUCTION 1 -Piece: QYes QNo Pump Required: QYes QNo OMay Be Required Nitrification Field Sq. ft. Pump Tank: Gallons No. Drain Lines 1 -Piece: QYes ONo Total Trench Length: ft GPM—vs-- ft. TDH Trench Spacing: _ QInches O.C. Dosing Volume: _ Gallons Feet O.C. Trench Width:_ nches Peet Grease Trap: Gallons Aggregate Depth: inches Pre -Treatment: ONSF OTS -1 OTS -II Septic Tank Installer Grade Level Required: 01 Oil 0111 OIV Dann 1 nf'2 CDP File Number 193988 - 2 County ID Number: M5 020 A0-o2o-A ❑ Open Pump System Sheet RepairbVSIem tcequired:vTes viva UUL Ildb /1Vd11dU1C 0 I —— —'` .. Trench Spacing:OInches 0., *Site Classification: Provisionally Suitable Feet O.C. Trench Width:Q Inches Design Flow: _ Feet Aggregate Depth: Soil Application Rate: inches Minimum Trench Depth: "System Classification/Description: Inches TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover Inches Maximum Trench Depth: 'Proposed System: 25% REDUCTION Inches Maximum Soil Cover: Nitrification FieldSq. Inches ft. No. Drain Lines *Distribution Type: GRAVITY -SERIAL Total Trench Length: Pump Required: OYes ONo eMay Be Required \ Pre Treatment: ONSF OTS -1 OTS -11 'Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. *Permit Conditions The issuance of this permit bythe Health Department in no way guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. ' This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the improvement Permit, not to exceed five years, and may be Issued at the same time the Improvement Permit Issued (NCGS 130A -336(b)} If the installation has not been completed during the period of validity of the Construction Permit, the information submitted In the application for a permit or Construction Authorization is found to have been Incorrect, falsified or changed, or the site Is altered, the permit or Construction Authorization shall become Invalid, and may be suspended or revoked (.1937(g)). The person owning or controlling the system shall be responsible for assuring compliance with the laws, rules, and permit conditions regarding system location, Installation, operation, maintenance, monitoring, reporting and repair (1938(b)). Applicant/Legal Reps. Signature Required? Oyes ONO Applicant/Legal Reps. Signature' Date: *Issued By: 2140 -Nations, Robert Date of Issue:. 0 8/ 1 0/ 2 0 1 6 Authorized State Agent: Malfunction Log OYes @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION 193988 - 2 Davie County Health Department CDP File Number: 210 Hospital Street M5 -020 -AO -020-A P.O. Box 848 County File Number: Mocksville NC 27028 Date: 08/ 1 0/.1 0 1 6 Olnch Drawing Drawing Type: Construction Authorization Scale:. O ON/A CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 CDP File Number: 193988 - 2 County File Number: M5-020-Ao-020-a Date: .0.8 / 1 0/ 2 0 x 6 Click below to import an Image from an external location: Drawing Type: Construction Authorization HEALTH DEPARTMENT RELEASE bavie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 r For Office Use Only *CDP File Number 193988-1 M5 -020 -A0 -020-A County ID Number: `Evaluated For: HDRMWC Phone: 336-753-6780 Fax: 336-753-1680 PERMIT vAUD 0 5/ a 0/ a 0 a 0 UNTIL: Applicant: Roger P. Spillman Address: PO Box 738 City: Cooleemee State2ip: NC 27014 Phone #: (336) 284-2551 Property Owner: Roger P. Spillman Address: PO Box 738 City: n(336)284-2�'51 State2ip: 27014 Phone #: Address438 Michaels Road Subdivision: Sallie Acres Phase: of 20 Road # Mocksville NC 27028 SINGLE FAMILY Township: 'Structure: Directions # of Bedrooms: 3 # of People: Hwy 601 S. right on Hwy 801 right on Michaels Rd 'Water Supply: PUBLIC Basement: ❑ Yes a No Type of Business: ` Total sq. Footage: No. Of Employees: This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps. Signature Required? OYes ONO, Applicant/Legal Reps. Signature; *Issued By: 2140 -Nations, Robert Authorized Stat Agent: gent: 'Date: / *Date of Issue: 0 5/ a 1/ a 0 1 5 **Site Plan/Drawing attached.** OHand Drawing Olmport Drawing c r I HEALTH DEPARTMENT RELEASE . Davie County Health Department CDP rile Number: 193988-1 210 Hospital Street 4 M9 -020 -A0 -020-A P.O. Box Bas County File Number: Mocksville NC 27028 Date: 05 1211 a 0 1 5 Olnch Scale: OBlock = ft. Drawing Type: Health Department Release ON/A dop, tl �.WI, i. _O . �. ... dl c) .•JL4 age k 05/21/2015 10:21 3362846188 SPILLMANS PAGE 01 HLUE1 ED • DO' MAY 0 4 010 Davie County health DepartnienqC HEA TH Q�ie 6j�' Envirolu mental Healdi Se tion P.O. Box 848 210 Hospital Street , • Cotuier # ; 09.40M Mocks -.0e, NC 17028 Pheots (t336) - 763.67N0 pati• JW) - 733.1680 CIN -S W STEWATER CERTM CATION �j Ct (C ;�heck Onc) tgl$ccment Remodeling Reconnection Name' T� tZ. rC` o5 �C)m A NPhona Num er d2 ,�J� (Home) Mailing Address: -P; 0 i3v `, q3 (work) Detailed Directions To Site: 01 -'"lfi S R C o Pa;5,t I"'-8j/je- --6 43R 1'Y Lcanz-k.S - use -Pdt.35 'Rid %Jau property Addism 432) (fin t(jjdgLSC� Please Fill la The Following Information About The:EVST7NGTAtility Naxne 3ystom Installed Under: �'jn '3�� Date Systefn In tea ( ttt/Date/Xear): ? a - 9P� iunbor Of Beooms: Is The Facility Curremly Vacant? No if Yes, For Now Long? DD Any knowallobltms? Yes C :N-',), lfYcs, Fxplain; l.r.nc - - t�LLI 3 N ber Of Peopto: Please Fill In The Following Information About The NEW Facility: Type OfVacility: _,-, NtMiber0fBa Pool Size: Size: _ -00w: �►tN=ted By; �--r _ bete room&: ___ N ofPeople��•• xoy,rested:_ _ ze ly -- 1-5-, For ,�vironmcnW Health d�hce Use Approved Disapproved Comments; Envirenmontal Health Specialist Date: "The signing of this form by tht: lrnvimmnental Health Staff is'iri no way in tided, nor should be (extended or limited) that the on-site wwtewltcr systom will function p�opetly for any givers � ee» as a guarantee loriod of time. Payment. Cash Check Money Order lt,_ _Am"t•$ Tate: Paid By: Received By: Account q;�� } _ _Itivoice N 'L :+VL� ids I��- 'l�55 A•11 !. 't;1 Q 1 •(i �! , ���Y Phone: (336) - 753 - 6780 RECEIVED MAY 0 4 2015 Davie County Health DepartmenyC HEALTH Environmental Health Section P.O. Box 848 210 Hospital Street Courier #: 0940-06 Mocksville, NC 27028 ON SIT WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Fax: (336) - 753-1680 Name: )\O G EIZ L ` %_5 X01 11 m R N Phone Number c2 -3 q-)_5_51 (Home) Mailing Address: 7D, O , i5o � °7 3 � a? Q- -L 5-S/ (Work) Cao l"s=►xe-IF_ /VC-x.7011/ II ld - ozo �AC� - G z0A Detailed Directions To Site: t 0 1 S +C M l C H A EI1 Z d� - 't�uR n R+ 0 n M t Circa l5 C o Past is'- L 4-o 431 mtcN AEI S - 3usJ -Pa5s Rick 10Rg Property Address: L 6 kk Qn 1C H R ! C fy'lUc ILS V (_UC - Please Fill In The Following Information About The E US777VG Facility: sf1 LU U A(W c - Name System Installed Under: ! 6 & E Type Of Facility: c3D0 -I t' %a n - 1 o L�UG,Gc Date System Insled (�oL/Date/Year): ? 1 �' 9� +3 �r1Y�u L Of Bedrooms: 3 Number Of People:_ Is The Facility Currently Vacant? es) s)No If Yes, For How Long?�D O `J^ Any Known Problems? Yes No If Yes, Explain: Please Fill In The Following Information About The ArEW Facility: Type Of Facility: Number Of Bedrooms: Number of People Pool Size: Garage Size: Other: XRequested By: Date Requested: ,.-(Signature), ----- � For Environmental Health Office Use Only Approved Disapproved Comments: Environmental Health Specialist Date: *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # Amount:$ Date: Paid By: Received By: Account #:��n7 -Invoice #: ;. .. ( . r. - ♦ r }I...:. ""1 .. vI .i t .. -— Z ems.- ...�...:�� .,�tl AUTHORIZA.ION NO. '0703- DAVIE COUNTY HEALTH DEPARTMENT Yµ . Environmental Health Section PROPERTY INFORMATION-� Permittee''s , \� P.O. Box 848 �+ � U� Name:�f3�— Mocksville, NC 27028 Subdivision Name: .- T �`�'Ul'u•�{� r.- Phone #: 704-634-8760 ^•— ,��►�" Directions to property: �* j t��' ^ Section: Lot: ..r8 � AUTHORIZATION FOR l WASTEWATER Tax Office PIN:#; � - - L ,. SYSTEM CONSTRUCTION Road Name: **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) } ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION # _ `J IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST . DATE ISSUED M• .wty •..��N 1` �+�.�t Thr? -Ty � M •.. '' i ` ' I � • `4 "fV `%��CY DAA COUNTY HEALTH DEPARTMENT' IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Subdivision Name: Directions to property: �"+ Lot Section: 8 �a IMPROVEMENT PERMrr Tax Office PIN:#511� - IT ° Road Name: �\t S Zip: y} it **NOTE** This Improvement Pest DOES NOT authorize the construction or installation of.a septic tank system or any wastewater system. An AUTHORIZATION,FOR�WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the constcuction/mstallatibn of a system or the issuance of a building permit.. (In compliance with Article 11 of G.S. Chaptea 130A, Wastewater Systems, Section'. 1900 Sewage Treatment and Disposal Systems) aa ***NOTICE*** THIS PERMIT IS SUBJECT' TO. REVOCATION IF SITE . ; PLANS OR TBE PffENI?ED USE CHANGE, YOUR WASTEWATER ENVIRONMENTAL HEALTH SP DATE -ISSUED SYSTEM CONTRACTOR MUST SEE THLS PERMIT BEFORE , , INSTALLING THE SYSTEM. "`�+ ' ` • �. RESIDENTIAL SPECIFICATION: BUILDING TYP 1� QTA# BEDROOMS _ # BATHS # OCCUPANTS GARBAGEZISPOSAL: Yes o To COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SATS INDUSTRIAL WASTE: Yes or No LOT SIZE 0 6'4TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE�GAL. PUMP TANK GAL. TRENCH WIDTH• � 4 ROCK DEP'T'H � � a LINEAR, Ff. REQUIRED SITE MODIFICATIONS/CONDITIONS': **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. &4 THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760. �1 r• � X **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. &4 THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760. �1 APPLICATION FOR SITE EVALUATIONAMPROVEMENT • Davie County Health Department Environmental Health Section P. O. Box 848 Mocksville, NC 27028 (704) 634-8760 ilk��uv�' MAR - 3199797 1997 ; pp I t 9i - ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSE ESS`— -- Q ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed r-4m'—X �• �I i` (fin Contact Person Mailing Addresses P�Oox Home Phone City/State/Zip Cho G CE. m L-4� , 1\1(-l(- "DInl �L Business Phone a p 04" QSS 2. Name on Permit/ATC if Different than Above :�Qr7e' QS aLnyP Mailing Address 3. Application For: ❑ Site Evaluation 4. System to Serve: ❑ House a/mobile Home - City/State/Zip ll� Improvement Permit & ATC ®,Both ❑ Business ❑ Industry ❑ Other 5. If Residence: # People I # Bedrooms 3 # Bathrooms t9 -J ❑ Dishwasher ❑ Garbage Disposal Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Other: Specify type N 1 A # People # Sinks # Commodes # Showers If Foodservice: # Seats # Urinals Estimated Water Usage (gallons per day) # Water Coolers 7. Type of water supply: lid County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Zfl No If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: o(p, ix, Soo 1 WRITE DIRECTIONS (from Mocksville) TO PROPERTY. Tax Office PIN: # /O 1 U 1 foot 4o M-1 � Property Address: Road Name City/Zip rncy' K 5 L1 i L L F4 I✓C'i 0 r% Lia 8 1 FORE DQ fi x If in Subdivision provide information, as follows: 1 Name: 1 Q� 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 as necessary to determine the site suitability. DATE �` s SIGNATURE Revised DCHD (06-96) ' 0 conduct all testing procedures APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI U Davie County Health Department Environmental Health Section l f P. O. Box 665 Mocksville, NC 27028 EALTFi f�� r 1. Application/Permit Requested By r©h o 'a✓�m_st'.- e-- C• Nrtyi ri / Mailing Address' �"�_ i I.t�l(r✓;�_� Home Phone (o �'``f' 3g 33 Business Phone -u 7 s2 `✓" s� 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 5. If house, mobile home: Subdivision IT tlf)BJD Section _ Lot # JUL 2 11995 - CONSENT 1995 ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms ❑ Washing Machine No. of Bathroomsf�- 04 S ❑ Dishwasher —ipDwelling Dimensions 100 �g ❑ .Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: ublic ❑ Private 8. Property Dimensions _,L/jd O F7'— &--70©F/Sewage Disposal Contractoi 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? If yes, what type? ❑ Yes "o ❑ 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: 0 l b ✓� D V -S This is to certify that the information provided is correct to the best of my knowledge, incurred from this application. DATE I understand I am responsible for all charges SIGNATURE` CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED F?ROPERTY 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 representativ of the D e Co my Health De artment to enter upon above described property located in Davie County and owned by .vtxo fodhi �2dv;ce_ to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. 2_4s.-�, s DATE DCHD (1 193) '1 DAVIE COUNTY HEALTH DEPARTMENT ��� 4 ' ' Environmental Health Section Soil/Site Evaluation ,_,�'� NAME / DATE EVALUATEDnC� ADDRESS PROPERTY SIZE /075 PROPOSED FACIILTYc4l�,S�P LOCATION OF SITE Water Supply: On -Site Well _ Community Public G� Evaluation By: Auger Boring Pit_ 9Z Cut FACTORS 1 1 2 3 4 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture groupG Consistence i Structure 5/.t 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 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 :lay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay CONSISTENCE Moist VFR- Vc-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/ft2 DCHD(01-901