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124 Self Lane Site 2DAVIE COUNTY HEALTH DEPARTMENT ! Environmental Health Section d, P.O. Boa 848/210 Hospital Street Mocksville, NC 27028. L (336)751-8760 7 IMPROVEMENT(OPERATION PERMIT Account #: 989900024 Tax PIN/EH #: 5746-10-4874.01 SITE) Billed To: Roger Spillman Subdivision Info: Reference Name: Location/Address: off Michaels Rd -27028 Proposed Facility: Residence Property Size: 6.626 acres ATC Number: 'J y I ok **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 K 110ME #Peopleq #Bedrooms 3 #Baths 2— Dishwasher: Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type /� f,'C:Ni 7 #.PPe>13ople #People/Shift #Seats Industrial Waster Lot Size �2 of �' Type Water Supply (iDesign Wastewater Flow (GPD) �2 Site: New � Repan ❑ System Specifications: Tank Size ( GAL. Pump Tank GAL. Trench Width3(v ' t Rock Depth If 1 Linear Ft. 'Other: �I�TRtto� iC1'-_S� �tJ�Tall Lir1ES �tO.c. ta��r� Required Site Modifications/Conditions: CA), -)to 012 Veep S ccf- kbme nto U,51a 10 �i� s�iS IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISERS) IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection o this system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. 12-Lp•m. on the day of Nation. Tel hone # is(336)751-8760.*** t A4t�x 11�` � � Ce2Nt —rc> &F Ai 5 `i p CT I C6 icy "xall Environmental Health Specialist's Signature: Date: � c i 05/99 (Revised) I' ODAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900024 Tax PIN/EH #: 5746-10-4874.0 Billed To: Roger Spillman Subdivision Info: Reference Name: 3 y 1 R Location/Address: off Michaels Rd -27028 Proposed Facility: Residence Property Size: 6.626 acres ATC Number: 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 ONSTRU S VALI FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: 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 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. I A - tAON`r, /d ? . s' A IArti�1T� q -2 - Septic System Installed By:F Environmental Health Specialist's Signature: ate: a3 DCHD 05/99 (Revised) UJ/Z1/4UVJ AD:a9 JJt,ZH4b3UV b ILLMW YNUC of APPUOITION FOR SITE EVALUJITIONAMPIR)"ENT PERMIT 6 ATC Davie County Health Department BOX 84n/210 Eenpit emlotr P.O. Hoa ea8/230 Boay 270 Street Noctsvillm, ITC 27028 ' (336)751-8760 ^ V i IRFOIMTIOR is TRIS APP7.1/JITION CARNI HCP O fi„ INI'DIllATION I9 PROVIDED, Refer to the INFOMTZOTN VNLESB 11LT. TBC EEQp1pgD _5,o/ mall ImasTT1N for iustl'ectione• alllea �oo)q,r �/ & �1 eeev.ee ear.oe // aniline adae.ee /s - a / ,;.,G, OJ% YOY mmee . uLr/erceleis° a 0/ ' ave3aeee neon. - .�S "�r)jFE�je' �/ 2. YW on 9.ef16/ASD 1t Bltrereet rano rrl3aes aeaia.e :�• nj• ' Cih/esu/up a. Applieatlun Por:D Site Evaluation- 0 Improvewnt PermLt/ATC - - ROU t• ar.w to a rrioe: D Rome IYMobile Bow D Business O zndus try e. Te naaidenee: s people D Other a Ilsdroow a Bathroom of I OSeawalmr n e.rb.ae elepeeel (1'a�^o lrwr.tw o e...roavirvbl.e n ew..eeluJ rl.obirw e. Ie meele.n/bWvattY/eM.r: ' YM.Sey eyp. a ce . e abweee a Vrl„a1e _ - / waren Coo3na IP PDODSERVICE: t) Bolts Rebooted Water usage _ 4 tgallou Dee earl 7. Type of water supply; _I 9L County/City D well U Come pity s• Der" anticipate addittoer M npansio 3 of the AcilRy this "con IE Intended Jenne? O Yet )(No If yes, whsl type? _ Property Dimensions: G a (RD (P iq C- WRITE DIRECTIONS (hem Mv,k vgk) to PROPERTY: ^ Tal Office PIN: it 5144I0 497N PropertyAddrm: Rad Nsm �' I�M�Q C /�, h _ / _ n�C✓ye \ 11Y� / atyaiP L S Lw Q a✓ If to a Subdlvbke provide iefurmatbm, u Name: Section; Black: W. Hate 1��.� Properly ed:� 7'hb b to etl'ter that the tmformsliom provided is correct to the best of my heowltdg& I understand that may permU(a) Issued heron this areH"tisubject to smpeudou or reve"'oke, IT the Else pines or intended mn ehaege, ur if the Mforumtloa ae6milMd fe Ihb mppBofMs b ImbtBed or changed. 4 also, smderates l ruff am trapvteih/e for ail eddsEes ineaffedfrom Iiis application. 1, hereby, give consent to the Authorized RePreseutstive of the Davie County Health Department les enter upon above dneribed property )orated to DAVM County mod o to conduct all tallog preeedvm as Bectasary todetermlme the site suits 'y. -'-- DATE SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR 91TE PLAN(Ind a all Of rise followle Property Ilan and dhnsmsken, etroctures, nibaeW, nd npNc Iecallone). K Eabdmg sed propend Site Revisit Charge Dak(s): Client NoUBndon Date: EMS: q r - AcNmB1Na 2- RtWed D(7ip (07199) SITE CLASSIFICATION: i J EVALUATION BY: C)cer_ o.35To•�f , 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 tru ture 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 05199 (Revised) • • ON Ar • td11��Z�-®®®® SITE CLASSIFICATION: i J EVALUATION BY: C)cer_ o.35To•�f , 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 tru ture 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 05199 (Revised)