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589 Four Corners RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001320 Billed To: Arville & Robin Byers Reference Name: Proposed Facility: Residence ? 9'- �)-FCD 0 - Tax PIN/EH #: 5823-29-1104 Subdivision Info: Location/Address: Four Comers Road -27028 Property Size: 5.065 acres ATC Number: 2520 **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 #People _ #Bedrooms #Baths Dishwasher: zr, Garbage Disposal: ❑ Washing Machine: u Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size t5AC Type Water Supply {�/ Design Wastewater Flow (GPD) ( Site: New Repair ❑ System Specifications: Tank Size/6`7P b1 GAL. Pump Tank Other: 1! �' GAL. Trench Width *� �/ Rock Depth /J Linear Ft" Required Site Modifications/Conditions: �.,.�� ( 1 �2 -0-&�fc 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 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.**** R Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001320 Billed To: Arville & Robin Byers Reference Name: Proposed Facility: Residence ATC Number: 2520 Tax PIN/EH #: 5823-29-1104 Subdivision Info: Location/Address: Four Comers Road -27028 Property Size: 5.065 acres 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 WASTE WATE O TRUCTION IS VALID F R PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: eY4—ls 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 Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001320 Billed To: Arville & Robin Byers Reference Name: Proposed Facility: Residence ATC Number: 2520 Tax PIN/EH #: 5823-29-1104 Subdivision Info: Location/Address: Four Comers Road -27028 Property Size: 5.065 acres 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 WASTEWATERXONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: g, A- Date: -F7 - le "4U 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: APPLICAMON FOR SITE EVALUATION/IMPROVEMENT PERMIT A ATC Davie County Health Department Enviiunmenfat/ Heaft SecOfon P.O. Box 868/210 Hospital Street Mocksville, NC 27026 t (336)751-8760 U, 'A�vi r"OuT 00ori # IMMTAWZ*** TRIS UPLICRTION C NMT BE >PRO 95ED OHLZSS AIM %W RZQVIRZD iNI' MWION 18 PROVIDZD. Refer to the IN1' MWION BOLLZT111 for instructions. 1. pw to be siusd It ry i (1 4?,, 6 s,y :'i?, lam. �/e r S cos�taot person Hr u dt e D .3 $/c rs Nailing Address Z'6(0 is" n ny Nt;r k L t r noes vbme 23(,)-71.;2- y75-9' city/stat./sip U.ilf�'s't�c1—� (��►. tJ C ai10�1 susumee phone 33/0) S-95=3/7/ U-PlcrStsrn Z. Mass on perait/A= it Different than Above Nailing Address City/state/six► J. Application for: 0 Bite evaluation /Improvement permit/= 0 Both e. systan to services 0 House IfMobile Roma 0 Business 0 industry 0 Other a. if Residence: # people y 9 Bedrooms -3 # Bathrooms' -- XJ Dishwasher O Garbage Disposal J2(Rashing Machine 0 pavement/Ol-mulag I] saaaaant/no pluebing S. If steins../Industry/Others speoify type /V # people # sinks # Commodes # showers # Orinals # water Coolers I! I=BZRViCe: # Seats estimated hater Osage tgaums per day) 7. Type of water supply: 0 County/City yrwell 0 Community e. Do you anticipate additions or expansions of the facility this system Is Intended to serve! 0 Yes 0 No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE 09WRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESIIBMITTED by the client with THIS APPUCATION. Property Dimensions: to 5- .4 e - Tax 081ce PIN: # Property Address: Rosd Name Fn t r Cc A n e r 5 i City/Zip If In a Subdivision provide information, as follows: Name: _ Section: Block: Lot: WRITE PIR%4' 0NS (fq m to PROPERTY: 140 4•i.. LQ �ra M Inlira q Sri's ft h+ 5o +o Coo G ,xe Z-4AJ o/t i -c4 %l7' ` ro✓v, Co Li r► e_ Sri o Z- r,:y bcr c - it -o' *4%-- Ill eyl —f—drive coca Date Property Fogged: This is to certify that the inlbrmation 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 no change, or if the information submitted in this application Is falsifled or changed 1, also, understand Mat 1 am responsible for all charges Incurred from this appllcadon. 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 ,Q to conduct all testing procedures as necessary to determine the site suitability. DATE _ _ SIGNATURE ffufXXD �l/,�� TMS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property Imes and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) n s B� 3`a�. I o Site Revisit Charge j Date(s): I Client Notification Date: IEns: Account No. Invoice Na I -7 �U Now � F�RMERCY1 S 83.42• / F (YADK IV pg�R95 o RE G. s 81 -v s- -V4 -DA • O N N D•8. (YA ARE,g A ti (INCLUDESS.R. 065 AC' ti w L,, 'Opp •�� Chu: \ �✓:'` r~ `'1! t✓��" LU • n �1 to s yam. "+F€z kr• l o :..5. L ' •�r - Z t APPLICATION FOR SITE EVMIJATiON/IMPROVEMENT PERMIT & ATC (5 lel t5 `. Davie County Health Department l Environments/ Hea/tfi SerdonI p P.O. Box 848/210 Hospital Street �E� - 3 1999 Mockeville, NC 27028 (336) 751-8760 ENVIROMIENTAL HEALTH DAVIE COU—NTY ORTANT*** THIS APPLICATION CZMWT BZ PIU=SSBD UNLESS mz THE REQUIRED IMIMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Hasa to be 2411ed I q� M ,C . Contact Person 5*7' 'Lc-' 2 Mailing Address . �O �+,e ( ri 9 Bos Novas 33 / / G�'- J 5933 city/state/211? 0 S i //6 At G 99 OAS swine.. f. 336 %f r 3533 Z. Has. on Perth/ATC if Different than Above Mailing Address City/stag/sip y. Application For: 144ite Zvoluation 0 Improvement Permit/ATC 0 Both e. systes to service: "cruse Mobile Home 0 Business 0 Industry EL-�er 3. If Residence: # People S # Bedrooms// 3 # Bathrooms -22 81ri.hwasher G Gia bags Disposal O�tasbing Maobins 0 sasasent/No Plumbing 6. If swine../Industry/Other: specify typo # People # Unks # Cossode. # showers # Vrinals # Nater Cooler. 17 IMSERVICZ: # Seats Zstimated Nater Us//age (gallons per dart 7. Type of water supply: 0 County/City U401l 0 Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes [(o If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: J ± /-��Gr-�"eS WRITE DIRECTIONS (from Modksville) to PROPERTY: Tax Office PIN: # S k2 3 MY/ y (0 d i /Y dA' -'`\ �o / Property Address: Road Name S��/�(�(.�2 .�N,4�1/°�t! k! J1i7Q City/ZipJ�p le o/d 'd uie 6,t9 -tees -4.'" C'c i Wei If in a Subdivision provide information, as follows: -& y Name: �� ✓il' [_E�u ✓ 7� Section: Block: Lot: Date Property Flagged: 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 ani responsible for all charges Incurred frons this appUcadon. I, hereby, give consent to the Authorized Representative of the Dpoe County Health Department to enter upon above described property located in Davie County and owned by �.�-�?t�.✓ Sxi i f �w� M to conduct all testing procedures as necessary to determine the site suitability. DATE ]A-3— q 7 SIGNATURE 9 iIli.vvc"cry e,?'r- TEAS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the foWing: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge I Date(s): I Client Notification Date: I EHS: Revised DCHD (07/99) Account No. 0 Jy Invoice No. l� BUD r' c —► ( OW OR FORMERLY) EDWARD PEELE D,B. 65. Pq. 295 N Ti E 9'• RE DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990000890 Billed To: Herman Spillman Reference Name: Herman Spillman Proposed Facility: Residence Water Supply: On -Site Well PROPERTY INFORMATION Tax PIN/EH #: 5823-29-1104 Subdivision Info: Location/Address: Four Comers Road -27028 Property Size: 5 Acres Date Evaluated: i� Community Evaluation By: Auger Boring I- Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH i c Texture group e- S C - Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence ; Structure bk' Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION t LONG-TERM ACCEPTANCE RATE a2 SITE CLASSIFICATION: ,, T 4& le 9/0 A LONG-TERM ACCEPTANCE REMARKS: TE: LEGEND EVALUATION BY: f� OTHER(S) PRESENT: 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 DCHD 05/99 (Revised) DAVIE COUNTY HE LTH DEPAIRTMUT ENVIRONMENTAL HEALTH SECTION P. 0. Box 848/210 Hospital Street Courier #09-40-06 Mocksville, NC 27028 Phone #: (336)751-8760 December 13, 1999 Mr. Herman E. Spillman 589 Four Corners Road Mocksville, NC 27028 Re: Site Evaluation/Four Corners Road Tax Office PIN: #5823-29-1104 Dear Client(s): As requested, a representative from this office visited the aforementioned site on December 8, 1999. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site, thQ site was found to be provisionally suitable for the installation of a modified, oversized on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions, please feel free to contact this office. Sincerely, Ag;st &. i�4aA - Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/mp Enclosure(s)