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Bailey Downs Lot 3 Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 990005300 Tax PIN/EH#: 5880-64-8887.03 &I'ley bOIJVS Billed To: Fred Bailey Subdivision Info: Lot#03 Address: 493 Bailey Road Location/Address: Bailey Rd-27006 City: Advance Property Size: 9.205 Acres w Reference Name: Proposed Facility: Residential Property **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this`office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. Permit Type: 1&w ❑Repair ❑Expansionf� Permit Valid for: f55Years ❑No Expiration Residential Specifications: #Bedrooms 1 #Bathrooms��- #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Desiga Flow(GPD):_l 6 0 Type of Water Supply: ounty/City ❑Well ❑Community Well As stated in 15A NCAC 18A.19E9(5) Site Modifications/Permit Conditions:. accepted Systems may algia be used System Type LTAR Initial rc.e .c 0, Repair &Cc Site Plan p Y d' ✓ Environmental Health Specialist Date i.p.11-06 �IT SITE EVALUATION/IMPROVEMENT PERMIT & ATC t Davie County Environmental Health 1p 09 P.O.Box 848/210 Hospital Street SUN 2 2O Mocksville,NC 27028 i --(336)751-8760/Fax(336)751-8786 NFA�Tx A licitmal palua ' nflmprovement Permit ❑ Authorization To Construct(ATC) ❑ Both T e of Applicati s" ew SyAbm ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATIONIS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed � eG',r,- Contact Person_ / � 5 Billifig Address i�� Home Phone �9 -geiO 9 City/State/ZIP ag We'_P_ NC 7 O fP Business Phone 9179 — /y3 5- Name on Perniit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: 51 Site Plan Eflat(to scale) (Permit is,'valid'foj'60 mont}is with site plan no expiration with complete plat.) Owner's Name lc-w y)-or A t 4:��/ Phone Number Owner's Address City/Stat /Zip Property Address P9" City—�� ,rz Lot Size ,2eg� Tax PIN# Subdivision Name(if applicable) Secti n/Lot# 3 Direct' o To Site: ti r/U A. 2-e'v ,' �" ��l 114--s If the answer to any of the following questions is"yes",supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes Bigo Does the site contain jurisdictional wetlands? ❑Yes 2NO Are there any easements or right-of-ways on the site? fl'i'es ❑No Is the site subject to approval by another public agency? ❑Yes leo . Will wastewater other than domestic sewage be generated? ❑Yes ®0 'e IF RESIDENCE FILL OUT THE BOX B LOW #People #Bedrooms #Bathrooms Z/ Garden Tub/Whirlpool es ❑No Basement: es ❑No Basement Plumbing: ❑Yes ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBdsiness Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested:. R Onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: 21County/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and riles. I understand that I am responsible for the proper identification and labeling of property lines and comers and locating and flagging r staking the houselfacilit`�le proposed well location and the location of any other amenities. Site Revisit Charge Property os-or owner's legal representative signature Date(s): rp — Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# Revised 11/06 Invoice# _ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990005300 Tax PIN/EH#: 5880-64-8887.03 Billed To: Fred Bailey. Subdivision Info: Fred Bailey Properties Lot#03 Reference Name: Location/Address: Bailey Rd-27006 Proposed Facility: Residential Property Property Size: 9.205 Date Evaluated: Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit / Cut FACTORS aA 2 ji 3 3 C 4 5 6 7 Landscape position Slope % j HORIZON I DEPTH Q 721 Texture groupG G Consistence p r Structure �} k Mineralogy k,P HORIZON II DEPTH Texture groupGt� Consistence f ; Structure K 590 Mineralogy _ HORIZON III DEPTH:.,-: , Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure - Mineralogy SOIL WETNESS - r/ RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE nRATE O SITE CLASSIFICATION: 1 'EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: 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 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 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) I TAR -I nno_tPrm a(-rP.ntnnrP rata-na1hinw/ft) TnTm Ac Inc in Imo! t f t i x i �T 4 • , , W ' h b N AREA= 9.205 AC. N i AREA= 9.097 AC. a `w % ,z OWER POLE PO - - - - - - - _ POLE