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123 Self LaneDAVIE COUNTY HEALTH DEPARTMENT 12 Environmental. Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 . (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002666 Tax PIN/EH #: 5746-21-4260 Billed To: Stacee Wyrick Subdivision Info: Reference Name: Location/Address: off Michaels Rd -27028 Proposed Facility: Residence Property Size: 1.409 acres ATC Number: 3422 **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 M. NDn-,Z #People #Bedrooms 3 #Baths 2 Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: Er Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type /� ,.,, #People #People/Shift #Seats Industrial Waste: ❑ Lot Size I.14M AWype Water Supply�—w"r' ' Design Wastewater Flow (GPD) G� Site: New gr Repair ❑ System Specifications: Tank Size IMAL. Pump Tank _ GAL. Trench Width :y o Rock /Depth) Z Linear FL -7C6 Other: f1�1s11�t� nod 2 —QInL t.�aEs 1 `o•�,i/ =M_ (�N. Required Site Modifications/Conditions: _ l,YSTAXL— ©0 CZa*X, ,'� St B(F IMPROVEII NT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW FINISHED RADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system betty 8:30 a.m. to 9:30 �&. or 1:00,p. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** tro U'CA Environmental Health Specialist's DCHD 05/99 (Revised) ry t^� I oD x Date: wv Account #: 990002666 Billed To: Stacee Wyrick Reference Name: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5746-21-4260 Subdivision Info: Location/Address: off Michaels Rd -27028 Proposed Facility: Residence Property Size: 1.409 acres ATC Number: 3422 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 WASTEWATER CONS ISVA `FFORRAA PERIOD F FIVE YEARS. Environmental Health Specialist's Signature: /Date: %� �3 CERTIFICATE OF COMPLETION 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. Ili' l t: L H 7 DA V -n r� -6 12--5< Septic System Installed By: ` Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) APPI CNTION FOR SITE EVALVATIOWIMPBOVFMENT PERbirr B ATC Davie County Health [)apartment y P-0. es BQi Hospital t . Mookovilla, Nc 27028 (330751-878owals - wOVsunPLICR=()R Owwo"r BB PROCSSSSD tD4,E88 ATS T� RE()DIRLD Rebs to the ntsOaanTrtm 1, paY to q sill" /� G p Aadr .D'"e.n !Wima.�.m Har/seawsse A'11 oa....e e (� i1�d�� .Kia..• ,sena a. MW m Dae•lC/Aye if DStArwk ra.n Ahow Math^, AddMm riay/mow1kip a. Application For: D Site Evaluation D Improvamaat Permit/ATC Both •' araew w aasvaw, ❑ BosaO 14 Mobile Bose O Bunionna O Iadwtsy O [)War S. I! 1re,adeMe: / People q_ 1 Bedrooms;L ,,,, //�� 1 Bathrooms U ,S.sausK CI Gssapa ai•p•aa1 e: •Tpasiap tyyd,y O ,a•rae4D1 lI �iW o s..w.ee/,o n,sstop if 1wlnwe/nwu•ray/Ou,.ri sp.al:r eyp. i 1 wool. _ 1 awu • eo..oe.a /ase.... .. / V.A.la 1 ,akK Cool". IP AT)DDSERVICE: i Seats 6atimatad Neter Daa a 9 (eaalma pw CL -Y)- 7. Typoa! Me tar supply: '� County/City - D well D Community a. Do You aatiNpata addhlom or "pan &iom of the futility Ibis syticm is In to serve! DYes ONo Myea, rrbat typet - - Property Dimension. 7O / iC ✓3%/e,,. f rO WRITE DIRECf10NS (faun MakITIO-) to PROPERTY: Tax MePIN:8 -7,40'�p .1 Tlrrl Izi PropertyAddreea: Road Name 1Vn+ �:p�T �yli0 LICh4S�p Rq Cityaip QGSS .; V n14)!21# 6,)1 Le4 1f In • Sabd)vition p ids Informlkro, u touowr jle,.(. Q•F 'ol 'Name: _hQC_1- 17.0_%I:Y10� NO Section: Block: Lat;. Dak Proper! Fl.ggW: 311103 T6b 'BID certify that the iaforMmdon provided Is correct to the best of my knowledge. I aadenfaed That any permll(s) Wood heraller arc sabJeN to antpe,t"m or rereutloa, if the Lilt Plash or iureaded oeo change, or M the Infsmaxor oo aWmlMed is this aPPOCRUM is fanned or changed /,afro rMersr,odrAarlam rerlroarfblejora/feAd nineamdfiom rAfr appllCar/o,. I, btmby, give eouienl to the Authwized Repysul f me D e C000ty Deolth Depot eat Io soler noon .bore described property located in Dane Countby to coaduet all tntiog'procedures as nectuary to determine the ty,DATE 703SIGNATURTRIS AREA MAY BE USED FOR DRAW)NG YOUR SITEPe all of We property Dna and dimer ' Erb and mons, NraCllDy, rel6aoks, and aentic loeadna•\. proposed Site Revisit Cbarge Date(e): C)imt NODOatlos Dntr. .p.� Acrome No Revised DCID)(p7ryg) /Git��ap .a �. U31:e11:1U7j JJb2'b4b188 bt-'ILL-MAM) rRut U1 'Davit County, North Carolina Spatial Data Explorer Page I of 2 Spatial Data 13Kpl@rerNorte Carcina �Ml Cffak m go Map to: c zoon*, r z,.o, * ot,.*,mp r wwmy.rP-SrC@1-B77R zeinFqdgr =ZK� r.pAdnae"#�04ro— OU.: 0 ('Cala. Wo CRY aftmd r cam* zw FWS—Y, res" Flo o r mum ftm r me"rom 17 ftmeft rsamwold FNiws—yl r son* r Tamuhive Multi6—r wba" Pm D*VW—" PWN Un" r abvdaem ry %am mw Fgu-m -sr Sw 4k 'SE L Parfet Data Find AdioiHing Parcels r Amm Pw Physical 0 LmWOWIT)IwIAH :fAC r Cm" am all A&k* r fte Dww awn ft" 8000 • AaoftWAkw*wfAWOWW8I3 • PW $748214210 • AWaty Ad*om • Lepel HAOSAC; MICHAELS ROAD e CAm=VZembWR-A • Oaftww VWRICX VALLIAM 0 0 Comm Cede IV"C! • O~Ad*VW,VWYRr-KWLLLAMD a Cy C06. • Gwn*WAd*om k WVRICK STACEE SPILLMAN 0 F"01119ft 71ft mp IV PmPI I • OWFPPdAd*m & 5119 MICHAELS ROAD 0 Fft6d&WZC*IEX haa in - of I**] I QW.5I@bZWMOCM%4LLE,NC 27W9-OWO • ftodcaTmOlAy Mie 6Y �a oswobd ftm ro • Lend Veew: ell Awom pkb.mWodw; wd dab. Umm & FbOdAPAPOO& M46Y rolled th http://66.209.132.254/"pWesrimap.cU[?name=DavieL_odx&Cmd—sParcel2&NCPIN=5746... 31612003 Consistence DAVIE COUNTY HEALTH DEPARTMENT Structure Environmental Health Section HORIZON 11 DEPTH Soil/Site Evaluation., APPLICANT INFORMATION MCM!1a �• ®®®®— PROPERTY INFORMATION Account #i 990002666 Tax PIN/EH'#:`5746-21-4260 HORIZON Ill DEPTH Billed To: Stacee Wyrick Subdivision Info`. Consistence Reference Name: < Location/Address:, off Michaels Rd -27028 Proposed Facility: .Residence Property Size: 1.409 acres 'Date Evaluated: L4 12— 'Water 'Water Supply: On -Site Well Community Public ✓' Evaluation By: Auger Boring i Pit !! Cut • RESTRICTIVE HORIZON tLITE ® FACTORS 1 2 -'.. 3 4 .. .: 5 6 7 '•, Landscape posit on Slone % Consistence Structure Mineralogy HORIZON 11 DEPTH Texture group I Consistence MCM!1a �• ®®®®— Structure ��®��® HORIZON Ill DEPTH Texture group Consistence ®G)•Y;V-®®®e Structure Mineralogy HORIZON IV DEPTH® -®OO groupTexture Consistence ®®®®®®® StructureMineralogx— • RESTRICTIVE HORIZON tLITE ® LLAJJIr'11;A 11V1V -� f 7 LONG-TERM ACCEPTANCE RATE -� y9a�ctl SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: t OTHERS) PRESENT: 1 REMARKS: LEGEND Landscape Position R - Ridge S - Shoulder L -.Linear slope FS T - Terrace of slope Flood thin slopeH - _. CC - Concave slope CV - Convex slope p 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 Moi VFR ;Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm - Wet NS - Non sticky SS : Slightly sticky S -.Sticky VS - VerySticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic Structure.. _. SC - Single grain M - Massive CR - Crumb OR - 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)