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109 Marbrook Dr Lot 29 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 i I OPERATION PERMIT I j Account #: 990002904 Tax PIN/EH#: 5758-02-9695 Billed To: Jeff Raynor S6bdivision Info: Marbrook Lot#29 Reference Name: Location/Address: 109 Marbrook Dr-27028 Proposed Facility: Residence Property Size: 39,996 Sq.Ft. ATC Number: 4814 **NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC 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. ��"" System Type: 0 Q S.T.Manufacturer YkAlf Tank Date y 2 9 Tank Size Pump Tank Size A✓/-4 System Installed By: E.H.Specialist:—% Date: 3o�r efo �S�� 2?4• lD9 ('�C N S I�> A Ii O i rd� 36- S 3' DCHD 11/06(Revised) i DAVIE COUNTY ENVIRONMENTAL HEALTH 1 P.O.Box 848/210 Hospital Street I O Mocksville,NC 27028 t (336)751-8760 Fax#(336)751--8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990002904 Tax PIN/EH#: 5758-02-9695 Billed To: Jeff Raynor Subdivision Info: Marbrook Lot#29 Reference Name: Location/Address: 109 Marbrook Dr-27028 Proposed Facility: Residence Property Size: 39,996 Sq.Ft. i ATC Number: 4814 Site Type: 0 ew ❑Repair ❑Expansion **NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. Residential Specifications: #Bedrooms J #Bathrooms d• #People Basement❑ Basement plumbing❑ Non=Residential Specifications: Facility Type #People #Seats usAodor rw& f Square Footage(or Dimensions of Facility) CO1'l't_ r �G� in3�C�Clt/ Lot Size Type of Water Supply: 316ounty/City ❑Well ❑CommunityWell jor i df 'i j D . n Stci I lay�`ay, System Specifications: Design Wastewater Flow(GPD)3 4FLO Tank Size 1/0�GAL.Pump Tank NI/+GAL. �+ �• j.t L' ' Trench Width Max.Trench Depth at Rock Depth Linear Ft. Site Modifications/Conditions/Other: As stated in 15A NCA 8A.1989(5� (327'qua f ,. �.. 4.:VVv�aG — v19M IT the Davie County Environmental Health Section for final inspection ot this system between 8:30—9:30a.m.on the day of installation. Telephone#(336)751-8760. 9•71e-C'q F- 1 -e�cl. G& A;' 0 %0 . .�, r J, f �� 0. ;` op A � v•g-3 Iuvironmental Health Specialist Datey-- -7 .,rur) 1 1 m4 rRP.,;�P.a� `AFII �tA-'TIO SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health t+ P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 Tn Ap ication For- a valuation/Improvement Permit (Authorization To Construct(ATC) 21oth i Typ pplication: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed .3 L4+ RA /.1vt- Contact Person BillingAddress 4?0 NwtflNkqhotm OR Home Phone 33(0—$53-67'73 City/State/Z1P VIVL 9,7 2-9 If Business Phone 336-240—g094 LI�1Wnu�o Name on Permit/ATC if Different than Above -,:�7 t}M{- Mailing Address S AYKK- City/State/Zip_5&Mr2 PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 months with��ss}*te plan,no expiration with complete plat.) SQ Owner's Name rr K. SCA NOYL Phone Number 33G-Z4v-, 1`,L Owner's Address 420 0o 1r tbqm 1012 City/State/Zip ON WCOO N L 2-72-F9 Property Address 1 pci YY1A R 154-ooK City�VluFNL Lot Size3-1.6111& -<f Tax PIN#$7 5602�IR Subdivision Name(if applicable) 1MA+QBRooK Section/Lot# ( Directions To Site:�4 E -to Sv1tN C,-dtS -Vur,* L.4 -j,.b Dry of If the answer to any of the following questions is"yes",supporting documentation piast be attached. Are there any existing wastewater systems on the site? OYes U No Does the site contain jurisdictional wetlands? OYes W401, Are there any easements or right-of-ways on the site? ❑Yes @? I Is the site subject to approval by another public agency? DY s Vzo Will wastewater other than domestic sewage be generated? Lames W155 IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms S #Bathrooms Z rS Garden Tub/Whirlpool klfes ❑No Basement. ❑Yes fNo Basement Plumbing: []Yes i;Ko 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:. dConventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: 6'County/City Water 0 New Well ❑Existing Well 0 Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 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 perinit(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 r ponsible for the proper identification and labeling of property lines and corners and locating and flagging or staJZ hour N ' ity location,proposed well location and the location of any other amenities. Site Revisit Charge Prop Amer or owne 's legal representative signature Date(s): Client Notification Date: Date EHS: Sign given OYes ❑No Account# Revised 11/06 Invoice# i l R 196 SF SN cv 257 Sf lot c -IB r - 39, 96 ell 93,24" 4 4 Nf L- a. -9318-08 Tc)juj J,7 ' 7418 -V Von 84RBARA F r, AL P8 8 X J91 VON SF L ICAT OST F ITE EVALUATION/IMPROVEMENT PERMIT & ATC 2 avie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 ENv�R��M ��� - (336)751-8760/Fax(336)751-8786 Applic or: Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Type of Application: ❑New System ❑Repair to Existing System DExpansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed (_�. �� 1-=.-; - (�Qye�,, p r.�--� Contact Person p.0 Billing Address .'��$ 1�,,,�X JJ 1 So�7 y Home Phone City/State/ZIP 14&&r4 4 414' Z 7UQ� Business Phone --3 Y0 15 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: ite Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name Phone/d N�umber ��0-3so3 Owner's Address o/ S�, !.� City/State/Zip_''-' Lc,—,; e- /QC. 2 7cv o(,, PropertyAddress J G�r•� C �a ,K,�_ City YI loc-ksj.d!/.z Lot Size c'eg,In iM 0. X q0 Tax PIN# -5 U 0k9'C71 q Z-,Al 2 � 5758-6Z-ar1Rs Subdivision Name(if applicable) ,� k Section/Lot# Directions To Site: HL,3y 4 L - T��^•+ Civ ��. S� tirl :s�� `e — 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 ONo Does the site contain jurisdictional wetlands? ❑Yes ONo Are there any easements or right-of-ways on the site? ❑Yes��o Is the site subject to approval by another public agency? e01' s ❑No Will wastewater other than domestic sewage be generated? ❑Yes BN—o-- IF RESIDENCE FILL OUT THE BOX BELOW St e. l .3 �4Q IMf, #People #Bedrooms 4� #Bathrooms 7- Garden Tub/Whirlpool (mss ❑No Basement: ❑ es ❑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: DUonventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: oun /Ci hWater ❑New Well DExisting Well ❑ CommunityWell Do you anticipate additions or expansions of the facility this system is intended to serve? D Yes a-1q If yes,what type? This is to certify tha a 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 rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or staking the house/facility location,proposed well location and the location of any other amenities. Site Revisit Charge Property er' or owno legal representative signature Date(s): j//- :2 Client Notification Date: Date EHS: Sign given ❑Yes ❑Noar Account# "7 X73 Revised 11/06 �� Invoice# u y.to, � In 00 v (� f'az Ai 'sn ,�s fty ti l r a'A N 3w 6149 Ic - RY,t'a. 1� "''�i i I +`d t `y1•s !"L 1 X03 t k,� � ,:{�)3 t }>f �1 Kt.°�n • r . r sfN" � r � .++ . t' •�,, •+. .i .r •rj 'f s r:g', 1��P. � `�'Yf ..#ti' '� ,'' 1., �,, ! $S Y.� tj CO , yFA ° .T' +�• t',.� :�3'��'� �'�:'+IRT".. :1 M ''. �, t' �1G�} e �,1 r 'tis �rl ,�' '+ .v^ ,'�i. ,a spa y�•� e1 "�{ `^ � �t� y � .�. � i�'... cu f.. alfjy 15 d JOHN CROTTS RD p��, 7648 5 MAD .. 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'kvi fir' - L-I; S 3.2.5P,06'- __ i '0 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section I Soil/Site Evaluation APPLICANT INFORMATION PROPERTY-INFORMATION Account #: 990004173 Tax PIN/EH#: 5748-83-9141.29 Billed To: Land First Development Subdivision Info: Marbrook Lot#29 Reference Name: Rodney Bailey Location/Address: Idlewild Road-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: i holco 11 Z Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit 11", Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope% Q 2b LA 7o HORIZON I DEPTH D•- - I' Texture group at-' 011 Consistence EEM() "SSP lEr5qsyI Structure I MineralogyI HORIZON II DEPTH I Texture group G L T I Consistence S I Structure 1 Mineralogy s t HORIZON III DEPTH 'SCJ 7- - I Texture group C-4&Dr� I Consistence II Structure I Mineralogy S-Irw ! I HORIZON IV DEPTH Texture group Consistence I' Structure MineralogyI I f SOIL WETNESS I! RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S III LONG-TERM ACCEPTANCE RATE p,Z O D•Z� I I SITE CLASSIFICATION: CS C�' U+ VALUATION BY: ! LONG-TERM ACCEPTANCE RATE: l7•Z7S OTHER(S)PRESENT: REMARKS: x21 C � t 29�. nJ .J Q e.�-�� C fi� 29 C. LEGEND Land s ape 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 N�tcs 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 05105(R �ised) i Davie County Environmental Health P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 990004173 Tax PIN/EH#: 5748-83-9141.29 Billed To: Land First Development Subdivision Info: Marbrook Lot#29 Address: 228 NC Hwy 801 North Location/Address: John Crofts Road-27028 City: Advance Property Size: see map Reference Name: Rodney Bailey Proposed Facility: Residence **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: ew ❑Repair ❑Expansion Permit Valid for: 0 Years..O o Expiration Residential Specifications: #Bedrooms #Bathrooms 2.5 People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): Type of Water Supply:121(founty/City ❑Well ❑CommunityWell Site Modifications/Permit Conditions: F[<-QVC )�QAi i '. System Type LTAR Initial 0 .27 Repair Z7o I Site Plan! - - "a T T n - 4�� �~a Dv AL y� 41;0 OCT � � . 4, �� ; 7 Q 2 � ti's OCT � 1 - - --- - - — — — 45'b?SI 3 .cam Environmental Health Speciali Date Z /0 e i.p.11-06