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126 Spillman Farm Trail . . . . � . � . . i Davie County Health Department ��ia f�' Environmental Health Section � _s�__ . . :; � ;- P.O.Box 848 . , C� � �'�� 210 Hospital Street � �.�. ��, Courier#: 09-40-06 .�c�.�� . �J � : ' � . Mocksville,NC 27028 � Phone:(336)-753-6780 Fax:(336)-753-1680 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Name:'""`-��e `S ��`��'�� J �"` �� \ phoneNumbe�������� `�� (Home) Mailing Address:�2.�( '��(/� "�i'�/l Gt( (Work) ��(���(S��TG���j ���Z� Email Address: Detailed Directions To Site: Property Address: �{'L/�„r2 Please Fill In The Following Information About The EXISTING Facility: , Name System Installed Under: I�v�.— �o/`1�I/yl��" Type Of Facility: l.CS� Date System Installed(Month/Date/Year): o���O Number Of Bedrooms:� Number Of People: -�s�he.�aci1;_t;�„rrPnrl � or How Lon ? Any Known Problems? Yes No If Yes,Explain: Please Fill In The Following Information About The NEW Facility: . Type Of Facility:�� (�.(.�� Number Of Bedrooms•�Number of People Pool Size: Gara Size:1,��X� Other: Requested By: Date Requested: b(p O�I � (Signature) - -� F nvironmental Health Office Use Only Approved D approved Comments: J '� -r2 S i�e Environmental Health Specialist Date: Z �� *The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee (extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # Amount:$ Date: Paid By: Received By: Account#: Invoice#: . . ! �'Rof'ERZ}'. � LIr�E . �� � � � . � : . � � � ; � , I.00� � � . • � � . .. ; � - . � / . . � , . cs� � ,r I C-�.:T—_____ �-Sp'— `E 2 � ` p �` - � . . _ \ �' � � � � � � � N Ew � � . J � (— Ejc,s���a 1-lo�,e f�pC//-� ' �°0�-�'---> �/��.AG-� o � � �/ �j . i aoo 5���- � � � � � � � , . � � - �a�C f ; � ,� . ��.._.,,z�_._.. � w I . �� . � , . _ v . � � � � � �9T � W/� L K1�.�_ � �. . � � � � � � � . � -' . <, � . . . . � � r Q . . �. � �e - � n . .,���� ; � . � �, - . _ . . � s.a . . � . � � . � , � . � - , r ' . _, • _� _. DAVIE COUNTY HEALTH DEPART'MENT t. '` Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 + Account #: 990003727 Tax PIN/EH#: 5823-27-1420 � Billed To: Brooke Spillman Subdivision Info: �Z(p S�j��/�l�i�/� rft2lYL TZf�/� Reference Name: Location/Address: Bethe��ne-'Z7028 Proposed Facility Residence Property Size: 2 acres ATC Number: 4200 As stated in 15A NCAC 18A.1989(5) accepted Systems may also be used AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST$E ISSUED 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 WASTEW CO ON IS ALID FOR A PERIOD OF FIVE YEARS. /�, � Environmental Health Specialist's Signatu : Date: `� /� O� 1�� CERTIFICATE OF COMPLETION , **NOTE** The issuance ofthis 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 t en as a guarantee that the system will function satisfactorily for any given period of time. M/ � ' c� � ^-1� , � v ,�- ��c.k � � ��� 4 � i�P.�-f��l ��1�i1� H S� �'�4►� =L � —r�rc �.�G�.'�-�1 i Yt�� ta-� ,.. J Rq��'� Septic System Installed By: �Z Environmental Health SpecialisYs Signature: � Date: DCHD OS/99(Revised) � a _ i , . �. , . DAVIE COUNTY HEALTH DEPARTMENT � ' Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-87C►0 IMPROVEMENT/OPERATION PERMIT Account #: 990003727 Tax PIN/EH#: 5823-27-1420 Billed To: Brooke Spillman Subdivision Info: Reference Name: Location/Address: Bethesda Lane-27028 Proposed Facility: Residence Property Size: 2 acres ATC Number: 4200 **NOTE**This ImprovemendOperation 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 QI�E #People 2- #Bedrooms � #Baths Zr� Dishwasher: Cd� Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: � BasementlNo Plumbing: � Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply � Design Wastewater Flow(GPD) (1(. Site: New� Repair❑ System Specifications: Tank Size��OOGAL. Pump Tank GAL. Trench Width �(c,�� Rock Depth �Z� Linear Ft.�flC�� As st�ted in 15A NCAC 18A.1969(5) Other: � �Is`����o� �'Xc�-�. accepted Systems may also be used Required Site Modifications/Conditions: �TQ�-�-- �►•j TO�Q I� �� F�M�.�.Zl.._ ��_-'� � �1� ,� - iN[P OV MENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6"BELOW FINI ED RADE. ****NOTICE: Contact a representative of the D 'e County Health Department for final inspection ofthis system ee �� .to 9:30 a.m. or 1:00 p.m.to 1:30 p.m.on tt�e y of' stallation. Telephone#is(33G)75]-87G0.**** . , N . ' (QD,J �. , �' �Ox "�4� � � ur�� r�.eR� �.IQ, •'�.��('�� ,/. -' �� �`� ' "-- � '�(L„ �` � ' / -;'�� ' E : 2�''-30'' , , .:.y . :; .\� �. : � � � s�.ti 3 � � �,� � ,� � � �� -� v �/� �,�,,� ��=�� �� ' j Environmental ealt Specialist's Signature: Date: ��0 � , �j�� � DCHD OS/99(R vise �J� < . ��� , � 1 . . , . DAVIE COiJNTY HEALTH DEPARTMENT • � Environmental Health Section r/� G� � � � _ o S , T P.O.Boa 848/210 Hospital Street / ` �'� Mocksville,NC 27028 (336)751-87C►0 IMPROVEMENT/OPERATION PERMIT ; Account #: 990003727 Tax PIN/EH#: 5823-27-1420 Billed To: Brooke Spillman Subdivision Info: Reference Name: Location/Address: Bethesda Lane-27028 Proposed Facility Residence Property Size: 2 acres ATC Number: 4200 **NOTE**T'his Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALJTHORIZATION 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 I 1 of G.S.Chapter 130A,Wastewater Systems,Section .1900 Sewage Treatment and Disposal Systems). THIS PERNIIT 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 �-1��`- #People � #Bedrooms 3 #Baths 2�� 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) .�00 Site: New�_Repair❑ System Specifications: Tank Size I�C�C7GAL. Pump Tank GAL. Trench Width��`�Rock Depth�2. Linear Ft.�� As stated in 15A NCAC 1$A.1969(5) Other: 3 �k5�-�.�I�TiA� � , accepted Systems may also be used Required Site Modifications/Conditions: �,,��rr�,;� � c�r�_ � 1�'c� ���r, � 1c�� ��..t.�r� I1�'IPROVEMENT/OPERATiON PERMIT LAYOUT- APPROVED EFE'LUENT FILTER RISER(S) IF 6 "BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis systen�etween 8:30 a.m.to 9:30 a.m. or 1:00 p.m.to 1:30 p.m.on the day of installation. 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Hox 848�210 Hospital Street M- Mocksville, NC 27028 �; (336)'751-8760 ENS'1ROh!P;1E;�TF,:.HEALTH _ � i +� � .r: •:� ***ItlPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFOFtMATION IS PROVIDED. Refer to the. INFORMATION BIILLETIN for ins�ructions. 1. Namo to be Hilled i ��� ' ` 5.�71 I � u.'� ' I Contact Peraon Mailing Address ��—1 , � �l.'1.�� Iioma Phone `��i� 1`"C+�� ���UJ City/State/ZIP �i(:- i�' �� .�lC f �`�U�� Busineas Phone( �.�c'���^:%��� / 2. Nama on Permit/ATC i Different than Abovo r� `�� Mailing Address City/3tate/ �r �� R 3. Application For: �ite Evaluation �I Im�irovement � it/ATC ❑ IIoth 4. Syatem to Service: �, Fiouse ❑ Mobila Homa ❑ IIuainess ❑ ,Industry ❑ Other 5. Type IIY8t8IIl requested: �\ Conventional ❑ conventional modified ❑ innovative pacCepted 6. If �tesidance: # People � # Bedroom� �_ � Bathrooms �Z, � ' �Diahwasher ❑Garbage Diaposal �iashing Machino �asement/Plumbing `�IIasement/No Plumbing , /� 7. IE IIuuineea/Industry /Other: verify type � People # Sinka . # Commodoa # Showera # Urinals ' N waL•or Coolera IF FOODSERVICE: �k Seata Estimated Watar Usage (gaiiona par day) t . e. , Type uf water aupply: � County/City � Well ❑ Counnunity 9. no You anticipate additions or expansions of tlic facility tliis systcm is intendcd to sci•vc? Cl Ycs �No If ycs,tivl�at typc? ***I11II'ORTANT";X NTS 1�lUST COh1PLLTE T1I� REQUIRL•D PROPGRTY lNrORMATION RL:QUL'STLD I3CL01'V. Githcr� I,AT or SITC PLAN 1LIUST BL•SUB��ITTED by thc clicnt �vith TIfIS APPLICATION. Propci•ty Ditucnsions: �G�'�ou�� WRITC DIRG��ONS(from lYlocicsvillc)to PROPC[tTY:` i;. �? !� 7 / ��+ / !` ��/� �I'Ax Of1iCC PIN: #���1c�C/��o� � /�D�I� "'dD� r l��/' T�OLf�L.c.r/�y i ,,I Property Address: Road Namc ` t'�(�-��-�• Qrts„C�fi3%� - l[���1 ����,/�Las� . r�` c�ty�z;n ��ck,Svi 11�e ��o�.� . �,.�,�: .�.�•� G�.� cv�O 6�� -.- � If in a Subdi��ision providc information,as follotivs: l���,( �� Namc: -- Section: Block: Lot: Datc liome cornci•s flaggcd: 7��►� D �""'' Tl�is is to ccrtify tl�at tlic information providcd is correct to tlic bcst of rny kno�vlcdgc. I undcrstaud tliat any pertnil(s) issued liercafter are subject to suspension or revocation,if the site plans or intended use chauge,or iC tl�c information submitted in tl�is application is f�isified or ctianged. 1,also,iulderslaurl that 1 nm respo�isiGle for a/!clirrrges incrrrred frau t/ris npplicatiou. I,hereby,give consent to tl�c Autl�orized Representati��e of tlic Davic Cow�ty IIealll�Deparhnent to cntcr upon abovc dcscribcd property lacat�d in Davic County and otivncd by to conduct all tcstiug proccdur�s�s�����Ssary co a�t�r►��;,��ti��s;r�su�r���i� �� � SIGNATUIZ� � ��U��� ► N�`'�"� DAT� �(� ��� CJ w. THIS AR�A MAY B�US�D FOR DRAWING YOUR SIT�PLAN(Includc all of thc follo�ving: �sisting nnd proposcd property lincs and dimensions, structures, setbacks, and septic locations). � Sitc Revisit CI►argc . Datc(s): Clicnt NotiGcation Datc: �I-IS: Sign given '. Account No. ��� � Revised DCIiD(05/03 I�rvoicc No. d �""3 � . � ,�. �<,.�� O 1 ��� x ,��.� Q- 336 t �� � cozn� � '�;�9� �v � / �,0 i � � ��ez, � ; / 356 V � / 0 QP \ / rv ��(/ .. / ' — —°� � � � �� � 'L`l' s N` iaow� 2 �P �L� .P f a,]C1 , 'o��, �� r z�o / � , � �z " s / f- ° � „ ��.; , / zssa / " / �a�,> � / :�«: a��� _ �-L, �<zo 303 ��S 9j ` -« ��. Oq M � i � !,Y � � � ' � ' � � \/ � . a 1 \ A � il � � �' 91 ,s���.d:.,, 1 � "'� \ ` 01ite � �5e1 � '+a iaoA = � . �Q.� � i Z i5ne \ �ti q9�a \ / � . , .. I \ / � i xmo N � � Ina�N i0I8� I � / a 3i>3 / � �� $i.,;��. . . - a a e g t ' 8 � �M � �9 �9n • � �.� i � � =`�� �.. ..> . / ^°� �°'°� GA E HILL WAY1r. � T � �)6Sft� - / � e ' �/C A � 171 \ // / �:� a9g2 — ..._. � t55=� " • 1 � .. .. � , � ,� � ► � �: � . . . . . . �. �. '� � V ' DAVIE COUNTY HEALTH DEPARTMENT - ,,� . Environmental Health Section Soil/Site Evaluation � y: APPLICANT INFORMATION PROPERTY INFORMATION « Account #: 990003727 Tax PIN/EH#: 5823=27-1420 ; Billed To: Brooke Spillman Subdivision Info: � Reference Name: Location/Address: Bethesda Lane-270 8 r, Proposed Facility: Residence Property Size: 2 acres Date Evaluated: 4 I �' �� � . Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut � � ;� FACTORS 1 2 3 4 5 6 7 Landsca e osition L, Slo e% 3 � � HORIZON I DEPTH D_ �_ �-L Texture rou trc— .SGt� Consistence Fc�9 S Structure �Q Mineralo ' HORIZON II DEPTH � — 2 �2... Texture rou L � Consistence " ; Structure ; ��IL. Mineralo • S..SV� `. HORIZON_III DEPTH 2•-3(0 2 � Texture rou (� SG� Consistence SJ �S5 Structure S Mineralo HORIZON N DEP'TH Texture rou Consistence " Structure ' Mineralo ' SOIL WETNESS RESTRICTNE HORIZON ' SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE , fl. SITE CLASSIFICATION: � EVALUATION BY: �1`=' � � �-. �u.w.� _ LONG-TERM ACCEPTANCE RATE: � OTHER(S)PRESENT:— � . �, REMARKS: "�Qv��41- �Qt1t Av 1 2a'"� • LEGEND {� L�ndsca,pe Positi n R-Ridge S -Shoulder L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Tenace FP-Flood plain H-Head slope �g . , 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 � .ON�IST .N . . a'IQ1St VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm � �. NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky _ ' NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic S r, ,r ' SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogv 1:1,2:1,Mixed Llois� 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 , DCHD OS/OS(Revised) i� � � _ � ■���■ n����■����■��������■�■■■�■������e���������s e ■■ ■■■����■■e��s���■■��■■■��■�■��■■��■��■■�o����■■�����e��::�e�e�■��■ ■v��o■■■■■■■���■■�■■■���■��■�■■��■�■�■�■■■■��■�■_:���■■�����■����■ ■■��■■��■■���■�r����■■��■������■■ ■���■�■������■■��■■�■■�������■■■ 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