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137 Marbrook Dr Lot 27 J ! 1 Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 i (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 990004173 Tax PIN/EH#: 5748-83-9141.27 Billed To: Land First Development .: Subdivision Info: Marbrook Lot#27 Address: 228 NC Hwy 801 North Location/Address: John Crotts Road-27028 City: Advance - Property Size: see map Reference Name: Rodney Bailey Proposed Facility: Residence i **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: Xew ❑Repair ❑Expansion Permit Valid for: 05 Years,01�o Expiration 22 � Residential Specifications: #Bedrooms #Bathroo S#People Basemen0 asement plumbing❑ Non-Residential Specifications: Facility Type #People-#Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): 0�00 Type of Water Supply:,21 ounty/City ❑Well ❑Community Well Site Modifications/Permit Conditions: System Type LTAR Initial ,z'-2.5— Repair i-2.5'Re air 2 7 Site Plan / _fti• I _ Intl T-1 A'U Q� m Q- 4 tiN't - rl 'win - JV i i Environmental Health Specialit4y Date . i i.p.11-06 1 1 1 V U © 71 IC$TIQ� F ITE EVALUATION/IMPROVEMENT PERMIT & ATC �`�� 2 avie County Environmental Health P.O.Box 848/210 Hospital Street \M�SP`HrAt�t1 Mocksville NC 27028 (336)751-8760/Fax(336)751-8786 i Applic or: Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility i ***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 Contact Person Billing Address Hoy ?-I / Home Phone City/State/ZIP 44&(.,r4 p /1/� 2•2�� Business Phone 6 - I Name on Permit/ATC if Different than Above I 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 P-v.,-k 1--,Z.,, Phone Number Owner's Address o L, City/State/Zip_ L,C, « /l JC z 24 3 0 C� Property Address__ J o G►v� C a �J_ City k5-- 'I/'R Lot Size c2P:In ap Tax PIN# 57V Subdivision Name(if applicable) k Section/Lot# �? Directions To Site: HL-3V (04 L 'ti- ��1^Y+ Cf v ��. S v:s L. `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 DNo Does the site contain jurisdictional wetlands? ❑Yes OVo— Are there any easements or right-of-ways on the site? ❑Yes��o Is the site subject to approval by another public agency? ea Y s ❑No Will wastewater other than domestic sewage be generated? ❑Yes B 6�- IF RESIDEN E FILL OUT THE BOXBELOW #People #Bedrooms Z-7 #Bathrooms 7-, Garden Tub/Whirlpool (mss ❑No Basement: ❑ es ❑No Basement Pl—ur bbiing ❑Yes ❑No. �f 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: M75nventional ❑Accepted ❑Innovative ❑Altemative ❑Other Water Supply Type: bounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 8-7q0— If NoIf yes,what type? 069 (,and- This is to certify tha a information provided on this application is true and correct to the best of my knowledge. I understand that li 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 u derstand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or Raking the house/facility location,proposed well location and the location of any other amenities. /- Site Revisit Charge Property er' or owne legal representative signature Date(s): 4`- ,22 Client Notification Date: Date EHS: i Sign given ❑Yes []No Account# 73 Revised 11/06 Invoice# i n � *- r �'� •. ( � fy� W 1 i '. y �����_ - �t„S !`� r � x Jl n' i.��' r �`_•. �'N?' �� s iP}'�. �1 � f ,� '�•'` ' :'"d '� ��'. yid' '� y; �S' ': A 4.�i f 1 '� F ' ♦ \ 1Y' d - ��, � - ,ak�^4 r € r f '°• ` \ �' c,1:.9 f ca �' � �„�f Fr f��•r -r�.'?a�' • x :�,�. ,9. ... r YS " `. 1,� is •� ,. p�``C � � f�.s {�1 '".F �^k } ' �R^�, �, •.k� civil .* �y r x i i• _ - z•�' .<� a s`�• it f ?�. �:. ^ �' � .q f `f t'. �. R to P. .J �O� _ t re$•aY -ti.q •":�,lc � '11 yw�` I r'- 46 r„ I d �i. M a • ' ��. * � eta armor '.+, �, • r�19� f - � �� ,�r , f * R � iff I f r i4 w � Vs, t it nsvol <� i � ,,����,`�;� .. Rte. � ,�► ��.` ..�r,� ,.�-� - �,, E_ 4 I Y n .f�`',y, ."a,:'."- ... __. } _� �,.�. _ .r• rf.r.``.•..�".ri..�r rtl, lR.t��.`I-c1 `. � .-� n. '`� .. JOHN CROTTS R 5 6 47 3 zo eez �"-,� �' �- I S21S02 pHNcsorrs FUAD 4 FOAD ail R3ej ._ (176) �� ze1 f3�31 a \ N (1. 17 5432 PaD GnB N \ (a 97 A) H 7210 a 9fiffiA � \ 6149 v rp (RZpq) (03A GA) 0181 9141 1 �n CeB2 a;) (,B,A 3 00 r SF � m i � PcC2 CeB2 �� �I �64 ®� GaD 1,5 c 160 1 W (16.9aA) 1 6144 z722222!WA GnC2 l `oGnB2 N � T< \ J X57 (Z 67A) 617 so 0061 [ 9545 an 1 J� (15]) !2831 M9 v, �fr• t , c- , \ \ ►�l v f� C sr all I; i_. . -- `•`331' � `t � � �: � E��; ', 4 - - ,v 1 � L_bIRE i Ibl` L ..Al, :,,IC - - L-i 5 @9'31'19' E ? L S 27.05'0@' E i L 3 S 76'42'37' E @; L 5 51'1:3'41' 7E ---- L-�; S 41'46'28'- -...�_ 71 L- 7 S 20'41'36' r 4i 131 L-9 S..05*^"24' x. 7E L-10 S 1254'33' r �' �F . 11?VL- Y i� .�— L-1' S _32.5e•03' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990004173 Tax PIN/EH#: 5748-83-9141.27 Billed To: Land First Development Subdivision Info: Marbrook Lot#27 Reference Name: Rodney Bailey Location/Address: John Crotts Road-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: 0-7 Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L I Slope% -Z t HORIZON I DEPTH p --7 i Texture group Consistence S l Structure 117 UI Mineralogyt HORIZON R DEPTH Texture group C_ 4 Consistence t Structure 0 Mineralogyt HORIZON III DEPTH - I Texture group ?_'r'QCj0 e-7l Consistence i Structure t i MineralogyS f HORIZON IV DEPTH t Texture group Consistence l i Structure I MineralogyM I SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE i CLASSIFICATION LONG-TERM ACCEPTANCE RATE 0,2,75i (J SITE CLASSIFICATION: PS EVALUATION BY: ' � I LONG-TERM ACCEPTANCE RATE: L�-� OTHER(S)PRESENT- REMARKS: RESENT:REMARKS Landscape Position LEGEND R-Ridge S -Shoulder L-Linear slope FS-Foot slope N-Nose slope a 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 3Yet 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 11.1 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) LTAR-Long-term acceptance rate-gal/day/ft2 DCHD OS/OS(Reytsed) ,: