126 Self Lane Site 1DAVIE COUNTY HEALTH DEPARTMENT e
Environmental Health Section
P. O. Boa 848/210 Hospital Street
MocksAle, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 989900024 Tax PIN/EH #: 5746-10-4874.02 (n)G'aT�)
Billed To: Roger Spillman Subdivision Info:
Reference Name: Location/Address: off Michaels Rd -27028
Proposed Facility: Residence Property Size: 6.626 acres
ATC Nurrlber: 3420
**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 • "0#1\.P— I#People L-1 #Bedrooms 3 #Baths 2
Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: e Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
t / �p�
Lot Size x Of t0 •�0�-�-+"I'y�ie Water Supply 60a -%t' Design Wastewater Flow (GPD)ccO_ Site: New Repair
System Specifications: Tank Size LOODGAL. Pump Tank GAL. Trench Width 3/p Rock Depth /y',Linear Ft. = U(J
Other:
Required Site Modifications/Conditions: 1 "14QtL O'J
u �jes q'D.G. P . I,.1.
Int
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.****
DCHD 05199 (Revised)
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DCHD 05199 (Revised)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 989900024 Tax PIN/EH #: 5746-10-4874.02
Billed To: Roger Spillman Subdivision Info:
Reference Name: Location/Address: off Michaels Rd -27028
Proposed Facility: Residence Property Size: 6.626 acres
ATC Number: 3420
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 I I of
G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CONSTR TIO VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signatur D Ca
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.
Septic System Installed By:
Environmental Health Specialist's Signature :
DCHD 05/99 (Revised)
Date:
1)3/21/2003 15:39 3362696166 5PILLMHNS. PAUL ne
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APPDICATION FOR SOE EYALWIION/IaPROpFMEM PFIIMIi &ATC
Davie County Health Department
. EnNronmmltr//fea/nh Sorppl '
2.0 Box 040/210 RogAtul Straat.
Mookeville, VC 27020 /
(336)731-0760 (/
••eyympRTyyy THIS APDLICnTION
INF M&VION IS PROVIDED. Relay to the BE p�S� X08 ALL TIM C`
INPOFMITION'00LLETIN !or Snxt=zuctiotl0n.. [`
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property Dimmslom: _ � lP t0 `� W W7'g DIRECTIONS (Gwa Maakn0lt) to PROPERTY:
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If to a Subdivision pinuide informmtm, Be follows: • •k..T 6�/-!t,
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Section: - Bloch Lot: -O
1).m Property l7agged:
Tho b to certify that the Information provided is correct to the hest of my hnowledga. I aedtrofaad that any parmil(sJ
Issued hemmer an eobJeel to smpention or revocation, If the site plass br Duawled eve ouderchaug,an thatfthe any peintormattou
tabvdOcdVthis hereby, gbfelmeatfled orcke /ako,andeoland/ha"r r"Poaslb/ejosallcharger/ncurtedfrom
Ihk appHcorlan. 4 hereby, glue cameo[ to the Authorised Represestattva of the Davie Cb®ty Health Department
to eater spm above described propertyloeated In Davie Comfy sVo
M toudmet all t0ttog procedures a geceaary, to determine the sitDATESIGNATURE77113 AREA MAY BE USED FOR DRAWD7I'. YOURSPIE PLAths fob ag: Erlrttn[end proposed
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3/6/2003
DAVIIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #:'989900024,. Tax PIN/EH #: 5746-10-4874
Billed To: Roger Spillman Subdivision Info:
Reference Name: Location/Address: off Michaels Rd -27028
Proposed Facility: Residence Property Size: 6.626 acres Date Evaluated:
Water Supply-.; On -Site Well
Community
Public-_
E✓Cut valuation By: Auger Boring Pit
FACTORS 1 2 3 4 5 6 7
LONG-TERM ACCEPTANCE RATE
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 Fl? - 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
VFR - Very friable FR - Friable FI - Firm VFI - Ve . ry 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 74?
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 chrorna 2 or less
Classification - S(suitable), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2
DCHD 05/99 (Revised)
Landscape position
Slope %
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: / 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 Fl? - 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
VFR - Very friable FR - Friable FI - Firm VFI - Ve . ry 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 74?
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 chrorna 2 or less
Classification - S(suitable), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2
DCHD 05/99 (Revised)