429 Hobson Drive Lot 16CONSTRUCTION For Office Use Only
AUTHORIZATION "CDP File Number 199144 -1
Davie County Health Department County 1D Number:
210 Hospital Street Evaluated For. REPAIR
•,� ,. P.O. Box 848 11,1ownship:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone: 336-753-6780 Fax: 336-753-1680 0 a% a 4/ a 0 a 1
Applicant: Robert S. Spillman rAddres7s:
er: Robert S. Spillman
Address: 219 Hobson Drive 219 HobsonDrive
City: Mocksville City: Mocksville
State/Zip: NC 27028 Statefzip: NC 27028
Phone #: / \ Phone #:
Address/Road #:
429 Hobson Drive
Mocksville NC 27028
Structure: MOBILE HOME
# of Bedrooms: 3
# of People:
*Water Supply: NIA
Subdivision: Holiday Acres
Site Classification: Provisionally Suitable
Phase: Lot: 16
Directions
Hwy 601 S. on right past crossroad at Hwy 801 and 601
Saprolite System? QYes *No
Design Flaw: 3 6 0
Soil Application Rate: 0 a 7 5
*System Class ification/Descrip#ion:
PD o LESS
Minimum Trench Depth:
a
4
Inches
Minimum Soil Cover.
1
a
Inches
Maximum Trench Depth:
3
Inches
Maximum Soil Cover:
a
4
Inches
*Distribution Type: GRAVITY- PARALLEL (eq. d•box)
TYPE It A. CONV SYSTEM (SINGLE-FAMILY OR 480 G R ) Septic Tank:
Gallons
*Proposed System: 25% REDUCTION 1 -Piece: OYes ONo
Pump Required: OYes ONo OMay Be Required
Nitrification Field 1 3 0 9
Sq. ft, Pump Tank: Gallons
No. Drain Lines 4 1 -Piece: OYes ONo
Total Trench Length: 3 a 7 ft. GPM vs— ft. TDH
Trench Spacing: _ 9 0Inches O.C. Dosing Volume: _ Gallons
Feet O.C.
Trench Width: 3 2Inches
�w Feet Grease Trap: Gallons
Aggregate Depth: inches Pre Treatment: ONSF OTS -1 OTS -11
I Septic Tank Installer Grade Level Required: 01 Oil 0111 OIV
I of q
CDP File Number 199144 - 1 County ID Number
Open Pump System Sheet
air System Required: OYes ONO ONO, but has Available Space
I — Trench Spacing:Inches 0.
*Site Classification: — --8Feet O.C.
Design Flow: Trench Width: 0 Inches
0 Feet
Soil Application Rate: Aggregate Depth: inches
*SystemClassification/Description: Minimum Trench Depth: Inches
Minimum Soil Cover Inches
*Proposed System: Maximum Trench Depth: Inches
Maximum Soil Cover:
Nitrification Field Inches
Sq. ft.
No. Drain Lines *Distribution Type:
Total Trench Length: ft Pump Required: Oyes ONo OMay Be Required
Pre Treatment: ONSF OTS -1 OTS -11
*Site Modifications
C
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 wayguarantees 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 ofthe improvement Permit not
to exceed five years, and maybe Issued at the sametime the Improvement Permit Issued (NCGS 130A-336(b)j If theinstalMon has not been
completed during the period of validity of the Constrmtlon Perm the Information submitted In theapplication 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
lnwIlcL and maybe 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; monttorinS reporting and repair
(1938(b)).
Applicant/Legal Reps. Signature Required? OYes ONO
ApplicanVLegal Reps. Signature,, Date:
*Issued By: 2140 - Nations, Robert 00 Date of Issue: 0 .1 / a 4 / a 0 1 6
Authorized State Agent-- Malfunction Log 0YeS
..
@Hand Drawing Olrnport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Construction Authorization
CDP File Number: 199144 -1
County File Number:
Date: 0 2/.2 4/ 2 0 1 6
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CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
CDP File Number: 199144 -1
County File Number:
Date: .0.;?1 a4 /;?016
Click below to import an Image from an external location: Drawing Type: Construction Authorization
CONSTRUCTION
AUTHORIZATION
a�a N Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Spillman
Address: 219 Hobson Drive
City: Mocksville
State2ip: NC
Phone #:
/Address/Road #:
429 Hobson Drive
Mocksville NC 27028
Structure: MOBILE HOME
# of Bedrooms: 3
# of People:
"Water Supply: NIA
For Office Use Onlv` l
"CDP File Number 199144-1
County ID Number:
Evaluated For: - REPAIR
Township:
PERMIT VALID UNTIL:
Property Owner:
Address:
City:
27028 State/Zip:
Phone #:
e Information
Subdivision: Holiday Acres
1 a/ 3 0/ a 0 2 0
Imat�Ca—lvin Spillman
219 Hobson Drive''
Mocksville
NC � 27028
Phase: Lot: 16
Directions
Hwy 601 S. on right past crossroad at Hwy 801 and 601
System Specifications
Dann I r%f'R
Minimum Trench Depth: a 4
Slee Classification:
Provisionally Suitable
Inches
Seprolite System?
OYes ®
Minimum Soil Cover.No 1 a
Inches
Design Flow:
3 6 0
Maximum Trench Depth: 3 6
Inches
Soil Application Rate:
0 a 7
5
Maximum Soil Cover: 2 4
Inches
'System Classification/Description:
*Distribution Type:
TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
_ Gallons
"Proposed System: 25% REDUCTION
1 -Piece: Oyes
ONo
Pump Required: OYes ONo
OMay Be Required
Nitrification Field
1 3
0
9 Sq. ft. Pump Tank:
Gallons
No. Drain Lines
3
1 -Piece: OYes
ONo
Total Trench Length:
3 a 7
ft
GPM—vs—
ft. TDH
Trench Spacing:9
—
Inches O.C. Dosing Volume: _
Feet O.C.
Gallons
Trench Width:Inches
3
gFeet
—
.
Grease Trap:
Gallons
Aggregate Depth:
inches
Pre Treatment: ONSF OTS -1 OTS -II
Septic Tank Installer Grade Level Required: OI Oil OIII
OIV
Dann I r%f'R
CDP File Number 199144-1 County ID Number:
❑ Open Pump System Sheet
A a i A a A
Kepair5ysteMKequlrea:VTes t'Jrvu �_Jrvu,uuLridsr+vdndurc,7NdL;C
/Repair System
Trench Spacing:
9 QInches 0.1
*Site Classification:
Provisionally Suitable
— Q)k Feet O.C.
Design Flow:
Trench Width:
0 Inches
3 Feet
3 6 0
— .@
Aggregate Depth:
Soil Application Rate:
0 - a 7 5
inches
Minimum Trench Depth:
a 4
"System Classification/Description:
Inches
TYPE li A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR
LESS, Minimum Soil Cover.
1 a
Inches
Maximum Trench Depth:
3 6
"Proposed System:
25% REDUCTION
Inches
Maximum Soil Cover:
a 4
Nitrification Field
1 3 0 9
_ _
Inches
Sq, ft.
.
No. Drain Lines
"Distribution Type:
GRAVITY - PARALLEL (eq. d -box)
3
Total Trench Length:
3 a 7
Pump Required: QYes
@No
{May Be Required
\
Pre Treatment: ONSF
OTS -1 OTS -II ,
*Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
a
*Permit Conditions
The issuance of this permit bythe Health Department in no wayguarantees 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 Penn It, not
to exceed five years, and Maybe issued at the same time the improvement Permit Issued (NCGS 130A-336(b)j 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 Authortzation shall become
Invalid, and maybe suspended or revoked (.1937(g)). The person awning 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
Authorized State Agent
Date of issue:. 1 2/ 3 0/ 2 0 1 5
Malfunction Log Oyes
®Hand Drawing Oimport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Construction Authorization
CDP File Number: 199144 -1
County File Number:
Date: 1 2/ 3 0/ 2 0 1 5
Q Inch
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CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
CDP File Number: 199144 -1
County File Number:
121Date: 2 1 3 0/2015
Click below to import an Image from an external location: Drawing Type: Construction Authorization
CDP Fife Number 199144-1 County ID Number.
Svstem Reauired:@Yes O No ONo, but has Available
❑ Open Pump System Sheet
ace
—"" ..
Trench Spacing:
O Inches 4.1
9
*Site Classification:
Provisionally Suitable
Feet O.C.
Design Flow:
Trench Width;
Inches
3 Feet
3 G 0
— , .
Aggregate Depth:
Soil Application Rate:
0 a 7 5
inches
.�
Minimum Trench Depth:
a
4
*System Classification/Descrip#ion:
,
,..
.
Inches
TYPE 11 A CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR
LESS) Minimum Soil Cover.
1
a
Inches
Maximum Trench Depth:
3
6
'Proposed System:
25% REDUCTION
inches
Maximum Soil Cover:
a
4
Nitrification Field
1 3 0 Sq. ft.
inches
No. Drain Lines
*Distribution Type:
GRAVITY -PARALLEL (eq. d -box)
3
Total Trench Length: 3 a 7 ftPump Required: OYes @No OMay Be Required
1-1 Pre Treatment: ONSF OTS -1 OTS -II
*Site Modifications
No grading or construction activity is allowed in areas designated for system and repairwithout approval of Health Department.
*Permit Conditions
The issuance ofthis permit bythe Health Department in no wayguarantees 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 maybe issued atthe same time the Improvement Permit Issued (NCGS 130A -336(b)). If the Installation has not been
completed during the period of ttalldity 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 forassuring 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: 1 a / , 3 0 / a 0 1 5
Authorized State Agent Malfunction Log OYes
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Construction Authorization
CDP File Number: 199144 -1
County File Number:
Date: 12/30/.1015
Q Inch
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CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
CDP File Number. 199144 " 1
County File Number.
121Date: 2 1 3 0/2015
Click below to Import an Image from an external location: Drawing Type: Construction Authorization
AlbTfjO RATION NO: DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section. PROPERTY INFORMATION
Peimittee's" ; .. '^'i P.O. Box 848 "
Name: / Mocksville, NC 27028 Subdivision Name:
Phone #:704-634-8760
Directions to property: Section: Lot: 3
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION "
Road Name: , rte" a'a,� ZiP• �fJ
**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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION,
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTWOECIALIST DATE ISSUED
= - DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permi
Name: s
' e .1
Directions to property:
Subdivision Name:
Section: Lot:
IMPROVEMENT
PERMrr Tax Office PIN:#
Road Name: ,'x 'Zip + `•� r:7
�.'
**NOTE** This Improvement Permit 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
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)
***NOTICE*** THIS PERMrr IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED! SYSTEM CONTRACTOR MUST SEE THIS PERMrr BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS —I-_ # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFf � IN
# SEATS ' INDUSTRIAL WASTE: Yes or No
%!
LOT SIZE x 0� TYPE WATER SUPPLY �� DESIGN WASTEWATER FLOW (GPD) ��� NEW SITE v REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE G'DI� GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH -/c) LINEAR FTo -[2
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
**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. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:_
AUTHORIZATION NO. _� OPERATION PERMIT BY: Nwl— DATE: ig O -W
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 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.
DCHD 05196 (Revised)
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT &
� Davie County Health Department
Environmental Health Section t� V
P. O. Box 848
Mocksville, NC 27028 MAR 2 4 1998
i=�=
I MIEWTALHEALTN
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESS D U) fflE COUNTY
ALL THE REQUIRED INFORMATION IS PRO
1. Name to be Billed 9kezz c' Jot Contact Person
Mailing Address 219 %If4 .Sd/?�/ . Home Phone :250Y-2061
City/State/Zip gl(e& JL16 1f' Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: ❑ Site Evaluation ❑ Improvement Permit & ATC IP/Both
4. System to Serve: ❑ House tJ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People Ll # Bedrooms —2o / .3 # Bathrooms 12
❑ Dishwasher ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Other: Specify type
# Commodes
If Foodservice:
7. Type of water supply:
# Showers
# Seats
County/City
# Urinals
# People , # Sinks
# Water Coolers
Estimated Water Usage (gallons per day)
❑ Well
8. Do you anticipate additions or expansions of the facility this system is intended to serve?
If yes, what type?
❑ Community
❑ Yes ❑ No
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAX-OUHE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: /, .k moi') �3md-mob 1 WRITE DIRECTIONS (from
�'/' 1 Mocksville) TO PROPERTY:
Tax Office PIN: # - ` Z - 1 r C
�X?tlj�
Property Address: Road Name A k0n l` 1
1 /i q O /l o cYl
City/Zip Ackawzv
1 0nc 6A'/ (I `1 4
If in Subdivision provide information, as follows: 1
Name: - Ace 1
1
1
Section: Lot #:
� 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 5;��//`y�'�'- to conduct all testing procedures
as necessary to determine the site suitability.
DATE " oC SIGNATURE
Revised DCHD (06-96)
YOU MAY USE THE BACK OF THIS FORM FOR DRAWING YOUR SITE PLAN.
9
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT-&
Soil/Site Evaluation
APPLICANT'S NAME DATE EVALUATED
PROPOSED FACILITY ,'VI 'Al PROPERTY SIZE/�IJ��Xia
SUBDIVISION / 4a ROAD NAME
Water Supply: On -Site Well
Community
Public
Evaluation By: Auger Boring Pit ,/ Cut
FACTORS
1
2 3 4 5 6 7
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: 6— EVALUATION BY: Z 4/Z
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
REMARKS:
DCHD (O1-90)
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
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