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135 Creason RdAccount #: 989900024 Biiled To: Roger Spillman Reference Name: Proposed Facility Residence ATC Number: 4003 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street �� " Mocksville, NC 27028 (33G)751-8760 tf Tax PIN/EH #: 5735-58-9601 Subdivision Info: Location/Address: Creason Road-27028 Property Size: 1.008 acres AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSLJED by the Davie County Environmental Health Section prior to issuance of any building permit(s). T'his 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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: �/.�� CERTIITCATE OF COMPLETION I**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit I has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and I Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any I, given period of time. Septic System Installed By: Environmental Health Specialist's Signature : ��/ Date: DCHD OS/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section ,' '� � P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-87(0 IMPROVEMENT/OPERATION PERMIT Account #: 989900024 Billed To: Roger Spillman / Reference Name: �u � �j.� �� G� Proposed Facility Residence Tax PIN/EH #: 5735-58-9601 Subdivision Info: Location/Address: Creason Road-27028 Property Size: 1.008 acres ATC Number: 4003 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction ofa septic tank system or any wastewater system. An AiTTHORIZATION 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 STTE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People 'l�' #Bedrooms �� #Baths �_ Dishwasher: � Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size � Type Water Supply �� Design Wastewater Flow (GPD) �� Site: New 4� Repair � System Specifications: Tank Size f�6bGAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width � Rock Depth ��Linear Ft.�! �i Ih1PROVEI�9ENT/OPERATION PERMIT LAYOUT - APPROVE FLUENT FILTER. RISER(S) IF (" BELOW FINISIiED GRADE. ****NOTICE: Contact a representative of D ie unty Health Department for final inspection ofthis system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 130 p.m. t of installation. Telephone # is (33C►)7.51-8760.**** `J`�-!D' d� e �� Environmental Health Specialist's Signature: DCHD OS/99 (Revised) Date: � S—� CATION FOR SITE EVALUATION/IMPROVEMENT PERhi1T & ATC Davie County Health Department Environmenta/Hea/ih Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ***IbSPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed � �� Contact Peraon �� Mailing Addresa ��v�� I� C 3� Home Phone �g �—�- �� City/State/ZIP �o v%e-��=--L _ euainess Phone ��O �f � �-s$ � 2. Name on Permit/ATC if Different than Above � v 1 Mailing Address ��c� fl��-td /►.J� W.e.�d • 3. Application For: ❑ Site Evaluation l S L' � /�-�/ �-eS � .��r�, �l C .�-?OS i1 City/State/Zip � O � � ❑ Improvement Permit/ATC � Both 4. Syatem to ser�ice: ❑ House �,Mobile Home ❑ Business ❑ Industry � Other _ 5. Type syatem requested: �Conventional ❑ conventional modified ❑ innovative 5. If Residence: # People _� # Bedrooms 3 # Bathrooms �� Dishwasher ❑Garbage Disposal MWashing Machine 7. If IIuainess/Induatry /Other: varify type # Commodes # Showers IF FOODSERVICE: # Seats ❑Basement/Plumbing ❑Basement/No Plumbing # Urinals # People # Sinks # water Coolers Estimated Water Usage (gallona par day) 8. Typa of water supply: C�County/City ❑ Well ❑ Community /� 9., Do you anticipate additiona or expansions of tlie facility this system is intcnded to scrve? ❑ Yes No If ycs, what type? ***IMPORTANT�** CLIENTS MUST COh�PLETE THE REQUIRED PROPGRTY INrORMATION REQUESTED I3ELOW. Either a PLAT or SITE PLAN MUST I3E SUBMITTED Uy tl�e clicnt with TIIIS APPLICATION. Property Dimensions: � � � � /'� T�X orr�� rirr: #��73 S- S� -%l� o l Property Address: Road Name (�-e �-.Sc� Yv ��; ' City/Zip If in a Subdivision provide information, as follo�vs: Name: Section: Blocic Lot: � WRITE DIRECT ONS (from Macicsvillc) to PROPGRTY: S � � � -� � �.- � �.�.�� 1 .S � 4-.� d � � n�-I C�-s -i�2,� � � n�1 �-(��5 d ^� � � . _.��F- �� `�wd�' ' Date I�ome corners tlag�ed: � a� O 5 Tliis is to certiCy that the information provided is correct to the bcst of my kno�vledge. I understand tliat any permit(s) issued liereafter are subject to suspension or revocation, if tlie site plans or intended use cliinge, or if tl�e information suUmitted in this application is falsificd or cl�angcd. I, also, «nderstnnd t1�nt I nm responsiGle jor al! cliarges incrrrred jronr tliis applicatiou. I, hereby, give consent to the Authorized Representative of tl�e Davie Cou�ity IIcaltli Department to enter upon aUovc described property located in Davie County and owned by to conduct all testing procedures as necessary to determine tl�e site suitability. DATE � i D � � s SIGNATURE .�— �� THIS �REA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of tlie fol(owing: �xisting and proposed property lines and dimensions, structures, setbacks, and septic locations). 0 Sign given � V v Reviscd DCHD (OS/03 Site Revisit Cl�arge � Datc(s): Clicnt Notification Date: �HS: ' 0 Account No. 7 � 9,��0 � � Invoice No. � r� .- �. • APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC ` ' Davie County Health Department � Environmental Health Section P. O. Box 848 Mocksville, NC 27028 (704)634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. j� � 0 /'�p 1. Name to be Billed 1�� Q e-r �� D ��%�Yl� Contact Person ^ � a""� Mailing Address �� }C / � � Home Phone ��-- � �� City/State/Zip ' � Q� Business Phone � ��'� `�� 2. Name on PermidATC if Different than Above l/�-v L''1"'l � f':. � ___�_�_-� � �' � . Mailing Address � �'1 � N �� -C�JI City/State/Zip � lX��i' C � / � � 3. Application For: j�Site Evaluation ❑ Improvement Permit & ATC j� , Both � / �( 4. System to Serve: ❑ House j� Mobile Home ❑ Business ❑ Industry ❑ Other / 5. If Residence: ishwasher 6. If Business/Other: 7 8 # People � # Bedrooms �_ # Bathrooms � ❑ Garbage Disposal �, Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage (gallons per day) Type of water supply: County/City ❑ Well 0 Community Do you anticipate additions r expansions of the facility this system is intended to serve? ❑ Yes � No If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH T�IIS APPLICATION. Property Dimensions: ( � o o � � Tax Office PIN: # 5� 3 _ S 5�' _ J� � Property Address: Road Name l� -e-�S� ciryiz�P If in Subdivision provide information, as follows: Name: Section: Lot #: WRITE DIRECTIONS (from Mocksville) TO PROPERTY: tnd( -E'n G ��5�"a�-w --{' U�� .� o n+-b 6�ac� S� /Y� i (� S `�� ( �Q�- O� C��as� � � L��- � (-e-F�� e 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 �"' �� to conduct all testing pr edures r"� as necessary to deternune the site suitability. � DATE �' l `� �� SIGNATURE � Revised DCHD (06-96) .• ., s • . 1 � �� j j,{� �t1 � 59 C/ O�i / � c� S� t' � �� _ r--� �`' G`' (`' 1�9 C� � n�� - � ,,, __ ._ ---, t . . _ i i� � , � . ;� '� �Y:.i! 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DAVIE COUNTY HEALTH DEPARTMENT , Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME �� / ` DATE EVALUATED �i�/fS� PROPOSED FACILITY �/ ,i PROPERTY SIZE `7�"C� SUBDIVISION ROAD NAME ,� � �S6 � Water Supply: On-Site Well Community, Evaluation By: Auger Boring Pit Public Cut REMARKS: DCHD (01 •90) OTHER(S) PRESENT: LEGEND � Landscane Position R- Ridge S- Shoulder L- Lineaz 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 frm Wet NS - Non sticky SS - Slightly sticky S- Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P- Plastic VP - Very plastic tructure SC - Single grain M- Massive CR - Crumb GR - Granular ABK - Angulaz blocky SBK - Subangulaz blocky PL - Platy PR - Prismatic Mineralo�v 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 - gaUday/ft2