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Bailey Downs, Lot 4 .. . Davie County Environmental Health P.O.Bog 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 990005300 Tax PIN/EH#: 5880-64-8887.04 Billed To: Fred Bailey Subdivision Info: Lot#04 Address: 493 Bailey Road Location/Address: Bailey Rd-27006 City: Advance Property Size: 9.229 Acres 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 Dlans,plat or the intended use change. , Permit Type: KNew ❑Repair ❑Expansion Permit Valid for: 5 Years ❑No Expiration Residential Specifications: #Bedrooms #Bathrooms #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats L� QQ Square Footage(or Dimensions of Facility) Design Flow(GPD): l U Type of Water Supply: Z7County/City ❑Well ❑Community Well Site Modifications/Permit Conditions: A5 stated In 15A Qyfems may also hr. ud1 System Type LTAR Initial r r - 7 �N Repair 1 \\ �f Site Plan VV 42 K Tib Environmental Health Specialist i.p.11-06 PEL FOIE EVALUATION/IMPROVEMENT PERMIT & ATC 4 2 2009 vie County Environmental Health .O.Box 848/210 Hospital Street 1. Mocksville,NC 27028 `t vt�,pNMthj����4� 36)751-8760/Fax(336)751-8786 DA�ILGGJ^iTl Applicati n Fo i e Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Type of Application: ❑New Sys'tbm ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATIONS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Y �f f� 41� /Name to be Billed /� e Contact Person / _ S Billifg Address ikeHome Phone City/State/ZIP fidaee-, C J O Business Phone 909- /V-5 Name on Permit/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: mite Plan Rflat(to scale) (Permit is'valid fo 60 mont)is with site plan no expiration with complete plat.) Owner's Name /CF�p� Tj1.y dpi' ,1 i �� Phone Number Owner's Address City/State,/Zip Property Address � City �/L8 Lot Size q,. ` �j Tax PIN# {� ' - M: � Subdivision Name(if applicable) Sectign/Lot# Directio To Site: 9d ,' -� 901 , e-4-i a 121 1' S e- - " r If S 'D ?l i ) If the answer to any of the following questions is"yes",supporting documentation must be attac ed. Are there any existing wastewater systems on the site? Dyes BIND Does the site contain jurisdictional wetlands? Dyes 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 RKo Will wastewater other than domestic sewage be generated? Dyes ®7 0 IF RESIDENEg FILL OUT THE BOX BELOW #People #Bedrooms #Bathrooms-Z- 'L Garden Tub/Whirlpool ❑ es ❑No Basement: Xes ❑No Basement Plumbing: ❑Yes ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business 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:. 213 onventional ❑Accepted ❑Innovative ❑Alternative 00ther Water Supply Type: D"County/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes F1 No If yes,what type? This is to certify that the infonmation provided on this application is true and correct to the best of my knowledge. I understand that any pen-nit(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 rules. I understand that I am responsible for the proper identification and labeling of property lines and comers and locating and flagging r staki g the house/facili proposed well location and the location of any other amenities. Site Revisit Charge Property owu is or owner's legal representative signature Date(s): � - Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# Revised 11/06 Invoice# DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section f,r Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990005300 Tax PIN/EH#: 5880-64-8887.04 Billed To: Fred Bailey Subdivision Info: Fred Bailey Properties Lot#04 Reference Name: Location/Address: Bailey Rd-27006 '-) Proposed Facility: Residential Property Property Size: 9.336 Acres Date Evaluated: Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit / Cut FACTORS ,(?r , 4 C 5 6 7 Landscape position Slope % HORIZON I DEPTH O G e ,C 7 Texture group G G r Ir Consistence ;; ,!1 _ + U Structure J_ Mine-ralogy HORIZON H DEPTH 411 Texture'group 'G L L Consistence ) Structure ,. �� 5. D " Mineralogy nd7 HORIZON III DEPTH l, TexturegroupConsistenceStructureMineralo HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE 17qIf CLASSIFICATION LONG-TERM ACCEPTANCE RATE d. 175 1 5 O. X SITE CLASSIFICATION: LEVALUATION BY: LONG-TERM ACCEPTANCE RATE: i 7 OTHER(S)PRESENT. t 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 lYat�s 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) TTAR -i.nno_tP.rm Ar-rPntanrP TAMP- 051UAaulft7 76 � S ' EXISTING 523 Q 1XV Q6 IRON _ S 89.59'01' E XOR f /-76-3 250.00 19877 2' EXISTING 2' EXISTING IRON IRON \ W W AREA= 9.229 AC. W ins AREA= 9.336 AC. in CD y y y 15 AC. • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990005300 Tax PIN/EH#: 5880-64-8887.04 Billed To: Fred Bailey Subdivision Info: Fred Bailey Properties Lot#04 Reference Name: Location/Address: Bailey Rd-27006 G Proposed Facility: Residential Property Property Size: 9.229 Acres Date Evaluated: -7 -Q l Water Supply: On-Site Well Community / Public: Evaluation By: Auger Boring Pit / Cut FACTORS 1. C 4 5 6 7 Landscape position Slope% '.1 HORIZON I DEPTH !> -5-rf 0 - Texture group Consistence tl* �- r Structure. i !/- Af Mineralogy v S i. HORIZON H DEPTH `?76-7/ ' - Texturerou (.. r. s Consistence PR611 Structure ? . k 6 Mineralogy HORIZON III DEPTH Texture group " Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE " CLASSIFICATION S LONG-TERM ACCEPTANCE RATE '17 SITE CLASSIFICATION: P;2 EVALUATION BY.. LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: U r 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 Moist •. CONSISTENCE 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 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) TTAR -Tena-term arrrntanrP rntP-aaI/rInuNt) Ally TT A[/A[ /T__:__-I♦ LE 76 � S EXISTING �0�8' IRON S 89.59'9Y E s362g5� F 7? 63 250.00 198.77 2" EXISTING 2' EXISTING IRON RON \ \ \ \ W AREA= 9.229 AC. W W AREA= 9.336 AC. { b! y y ►5 AC. TE EVALUATION/IMPROVEMENT PERMIT & ATC avie County Environmental Health O 2 �Q09 P.O.Box 848/210 Hospital Street JVN Mocksville,NC 27028 336)751-8760/Fax(336)751-8786 Applica ion F r: V� i on/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Type of pplicati ew Sysftm ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION-YS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Y f" Name to be Billed I' e Contact Person Billifg Address R,4 i,Le Home Phone1E -43 5�a City/State/ZIP d « MC700 lP Business Phone Name on Pernzit/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: O Site Plan 8'1''lat(to scale) (Pen-nit is valid fo 60 mon is with site plan no expiration with complete plat.) Owner's Name /edl i�� Phone Number Owner's Address City/state/zip Property Address MA e./ y City 11,14 ,0- Lot Size .'LZy Tax PIN#_ Subdivision Name(if applicable) Sectign/Lot# Directio To Site: 6q r5ti r/U A z,c�v d ,' ��/ �e� If the answer to any of the following questions is"yes",supporting documentation must be attac ed. Are there any existing wastewater systems on the site? Dyes RNo Does the site contain jurisdictional wetlands? ❑Yes&No Are there any easements or right-of-ways on the site? &Yes ❑No Pezve-r . -v— Is the site subject to approval by another public agency? Dyes Rl'o . Will wastewater other than domestic sewage be generated? Dyes 0 IF RESIDENCE FILL OUT THE BOX BELOW f If L #People #Bedrooms #Bathrooms 2 Z Garden Tub/Whirlpool DW-es ❑No Basement: ❑ es ONo Basement Plumbing: ❑Yes ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business 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: CN'County/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 corners and locating and flagging r staking the house/facility le6 proposed well location and the location of any other amenities. Site Revisit Charge Property owi is or owner's legal representative signature Date(s): Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# Revised 11/06 Invoice#