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328 Hobson Drive Lot 11-12, Section ADAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002030 Tax PIN/EH #: 5745-58-6166 Billed To: James Spillman Subdivision Info: Holiday Acres Lot # 11 &12 Reference Name: Location/Address: Hobson Drive -27028 Proposed Facility: Residence Property Size: SEE MAP ATC Number: 3000 **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 1F SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type bt&) M 14 #People #Bedrooms 3 #Baths 2— Dishwasher: Garbage Disposal: ❑ Washing Machine: d Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility,Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size �2+A Ck--s Type Water Supply Design Wastewater Flow (GPD) oO Site: New 2111" Repair ❑ System Specifications: Tank SizeI000GAL. Pump Tank GAL. Trench Width' Rock Depth 12- Linear Ft. Other: y -D STQt e-671 o -s Ge�� I te—`-'ST411 _ U . us T'O. C, Ul...� . Required Site Modifications/Conditions: 1�, z->T&L, t �h1� i � P S` Cop t'ouS� 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.**** �_ wm d �1 r S UffA CC (-,)A7P1Z- � i � �Le�►h��l� Fre.-L� Xl2" -1 �Gb� Ll.S t r 1 C�PS)c2 a Ro 4D ny Environmental Health Specialist's Signature: DCHD 05/99 (Revised) r"� �� i�5�0) ECDJ�VP —\ '15U 11 d f -SU" 2, " A U Chi P Account #: 990002030 Billed To: James Spillman Reference Name: ATC Number: 3000 DAVIE COUNTY HEALTH DEPARTMENT( }� 4 - Environmental Health Section �l P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH M 5745-58-6166 Subdivision Info: Holiday Acres Lot # 11 812 Location/Address: Hobson Drive -27028 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 Treat ent and Disposal Systems). THIS AUTHORIZATION FOR WASTEWA N T IS V LID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signatur : Date: 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. F Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: 1�7—/-1/e / APPUCATION FOR SITE EVALUATION/IMPROVEMENT PEIWIT & ATC Davie County Health�Department • ' Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 +aGT 3 i Zu�l t ENVIRONMENTAL HEALTH DAVIE COUNTY ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed _ (aWP_S l 1� I�yl(�Q.i_S ��' ( MQ n Mailing Address City/state/ZIP 06014P_070_0 lam(OC /v / 2. Name on Permit/ATC if Different than Mailing Address Ci 3. Application For: 4 Site Evaluation ❑ Contact Person�(f i/ Home Phone d841- Business Phone 4 Lt Permit/ATC Both 4. System to service: ❑ House 0I Mobile Home ❑ Business ❑ Industry ❑ Other S. If Residence: # People # Bedrooms # Bathrooms WDishwasher Fl Garbage Disposal Washing Maclaine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type. of water supply: fYCounty/City ❑ Well ❑ Community s. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 11101 0 If yes, what type? ***IMPORTANT*** CLIENTS MUST COdIPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLATT or SITE PLAN�M,USTBESUBM17TT�INvDl ED by t e client with THIS APPLICATION. Property Dimensions: D �C �YCI[.r� liv► RECTIONS (from Mocksville) to PROPER'll': Tax Office PIN: # .51/7415—S�8(O <a 00 1 S 470 Property Address: Road Name —,& !)n �r-t`G'� k2�S t ri CA City/Zip 110C c l �C�r�a�' h� i2 1- -:5 ICLL If in a Subdivision provide information, as follows: Name: << -I N � e4— Sid 4 Section: Block: Lot: J- I Z 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 am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davi County IIealth Departs nt to enter upon above described property located in Davie County and owned by C to conduct all testing procedures as necessary to determine the site suitability. calvilq be 1et+10 p!'%I P+-eQ h DATE 16— _�30 _ 0 SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge ax&k , Date(s): Client Notification Dater EHS: IUO�� jGd if- �0O tad rf /od Account No. Revised DCHD (07/99)Invoice No. rh 5z! ---Irl � q?-, LF 11412 o I I I ,,,T,,ArOeSm I'Chne- 1,5P DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002030 Tax PIN/EH M 5745-58-6166 Billed To: James Spillman Subdivision Info: Holiday Acres Lot # 11 &12 Reference Name: Location/Address: Hobson Drive -27028 Proposed Facility: Residence Property Size: SEE MAP Date Evaluated: /1 1 /01 Water Supply: On -Site Well Community Public Evaluation By: Auger Boring _V--, — Pit ✓ Cut FACTORS 1 2 3 R1 'i' -9, 6 7 Landscape ositionl— L Sloe % % HORIZON I DEPTH .- 10 Texture groupGV Consistence S SS Structure cv- MineralogyI ' HORIZON II DEPTH 1 2 Texture group Consistence StructureIL 5 Mineralogy HORIZON III DEPTH - (o Texturerou !_5J t -t Consistence : 5 Structure S k tQ 1- MineralogyI ` HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: r ' LONG-TERM ACCEPTANCE RATE: REMARKS: U /�1.� z Q A zmr 4 I EVALUATION BY: tet'+" % L� Gb4'1 ' 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 SICL - Silty clay loam SIL - Silty loam CL - Clay loam SC - Sandy clay SIC - Silty clay C - Clay CONSISTENCE Moist VFR - Very friable Wet NS - Non sticky NP - Non plastic FR - Friable FI - Firm SS - Slightly sticky SP - Slightly plastic VFI - Very firm SI - Silt SCL - Sandy clay loam 43 Sc7 EFI - Extre ely firm S - Sticky VS - Very Sticky k Az P - Plastic VP - Very plastic h�1 Structure SC - Single grain M - Massive CR - Crumb GR - Granul SBK - Subangular blocky PL - Platy PR - Prismatic 110 � ar ABK - Ang ilar blocky 42� Mineralogy 1:1, 2:1, Mixed 1/ i 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) i MEMO ■■■■■■■ass■■■■■■■e■■■■E■MEMS■■MM■■■■MM■ME■■■E■EEEEEE■■■■■EE■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■E■■■■■M■EEE■■■■■■■■■■■■■■■■■■■■■t■M■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■I■■■lin!�1i�111111■■11■■■■■■■■■■■■■■■■■■■■■■■■■■ MEMNON 003IMEMUNNEI■,1IN AMJEMEMENNEEMmmmommMENNEN ■■■■■■■■■■■■■■■■■■■■■■■■■1'11■■I!■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ --------------------------- ■■■■■■■■■■■■■■■■■■■new■■■■■■■■■i■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■'�w�■■■■■■■■i■■■■■e■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ iii■■■■■E\■■■■■■■■ ■■EEE■■■■EE■■M■■■■■■■■■■F+::aE��:��E■■E■■■■