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143 Marbrook Dr Lot 26 ` * DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street • Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 Q OPERATION PERMIT 3 Account M 990004407 Tax PIN/EH#: 5748-83-9141 a Billed To: Hire Custom Builders Subdivision Info: Marbrook Lot#26 Reference Name: Location/Address: Marbrook Dr-27028 Proposed Facility: Residence Property Size: 30,003 Sq. Ft. ATC Number: 4729 **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 NOWAY be taken as a guarantee that the system will function satisfactorily for any given period of time. Q � ' System Type: / S.T.Manufacturer �Cl� Tank Date l 1--)-Tank Size Pump Tank Size PP 15 d� System Installed By: 4\5 W;1i,o5D'ate:E.H.Specialist: o/ ? 1 I II \�(.s�t oda"� r L _ N C� c w •C DCHD 11/06(Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH ' P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990004407 Tax PIN/EH#: 5748-83-9141 Billed To: Hire Custom Builders Subdivision Info: Marbrook Lot#26 Reference Name: Location/Address: Marbrook Dr-27028 Proposed Facility: Residence Property Size: 30,003 Sq. Ft. ATC Number: 4729 Site Type: R1ew ❑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 3 #Bathrooms- #People Basement❑ Basement plumbinge' Non-Residential Specifications: Facility Type #People #Seats r.' Square Footage(or Dimensions of Facility) LotSize Type of Water Supply:XCounty/City ❑Well ❑CommunityWell System Specifications: Design Wastewater Flow(GPD)aloo Tank Size LOWGAL.Pump Tank GAL. Trench Width SGju Max.Trench Depth 2311 Rock Depth 12 Linear Ft. �y8 Site Modifications/Conditions/Other: VNSTau- C•J Contact the Davie County Environmental Health Section for final inspection of this system between 8:30—9:30a.m.on the day of installation. Telephone#(336)751-8760. As stated In 15A NCAC 18A.1969(5} accepted Systems may also be users P 'LOA 1574 Op I '70 t�•U-w— Zy0' i Environmental Health Specialist - Date: o7 DCHD 11/06(Revised) VU d * A. OR SITE EVALUATION/IMPROVEMENT PERMIT & ATC QDavie County Environmental Health P.O.Box 848/210 Hospital Street (� Mocksville,NC 27028 V 3 201 _ (336)751-8760/Fax(336)751-8786 J� ation For: to 1luati provement Permit1lAuthorization To Construct(ATC) ❑ Both ype natio : ystem ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility **IMPOR17A-NT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED ORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed 1Z'R6- et. 7Dirl •BUIL-bE Contact Person CI��L—/.nAI ARr Billing Address_.- O /K Home Phone 336-90-3--N3 City/State/ZIP . /1I(' ,�7D46 Business Phone_336—399 U Name on Permit/ATC if Different than Above . I Mailing Address City/State/Zip I 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 site plan,no expiration with complete plat.) ( I Owner's Name A'r, C-tks•}b m -Rudders Phone Number 5 3to-q 4 0 - 3 a 43 Owner's Address •P 0 Bt)X J'Rto City/State/Zip Addar\" tic- R-7 00(o Property Address Ako-'brao K —Dr, Lot- 02(o city Akac- S I I c- Lot Size 003 5q Tax PIN# .7 71$939141 Subdivision Name(if applicable) n)arbf oo K � Section/Lot# oZ Directions To Site: Frern hV t an W iIh r cry r - a1CZr ni �i.Li 4- o Cn rook dfo If the answer to any of the following questions is"yes",supporting documlFritation must be attached. Are there any existing wastewater systems on the site? ❑Yes*0 Does the site contain jurisdictional wetlands? ❑Yes XNo Are there any easements or right-of-ways on the site? ❑Yes ❑No Is the site subject to approval by another public agency? ❑YesNo Will wastewater other than domestic sewage be generated? ❑Yes PLNO i IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms 3 #Bathrooms 3 Garden Tub/Whirlpool Yes ❑No Basement: Yes ❑No Basement Plumbing: XYes ❑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:: #SSeats Type system requested; &conventional ❑Accepted ❑Innovative ❑Alternative ❑Other I q Water Supply Type: KCounty/City Water ❑New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Po If yes,what type? i 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 rules. I understand that I am responsible for the proper identification and labeling of property lines and comers and locating and flagging or sta 'ng he ouse/ il.ity location,proposed well location and the location of any other amenities. i MG Site Revisit Charge roperty owner's or owner's legal representative signature Date(s): 1 -7 Client Notification Date: Date r EHS: i Sign given ❑Yes ❑No Account# Revised 11/06 Invoice# e is Sol cS , I Ss c��JJ u `'. liJ N -h - r it t Sr G � L Oar brooK 1 AM � Ji 76 I,�t.CK t �\ ROME ft 9 - rax 6W!-• -t, I i 70 µou5v- Sc+ balc px -/o f-4- b ro(pp�dcc�d� 5 Z o+ lapprox I a7 -V4- wide- a+ -F tis•p't . l ti - �(ot,�5c ;s 15�� X66 sidc�3� �.�d 3�•5 �t �� . °�bl tae � • 1 -- ----- . - _ . r"i b ILIe- is a�Pcox � '�'� b+ aO X7. lz _ +r S fi 'L L . �I oO-.A ��.. � 91�-��' L°�a� Ma,-b�a►�� `1�i_re. Cus�a��3u�ldcrs Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 990004173 Tax PIN/EH M 5748-83-9141.26 Billed To: Land First Development Subdivision Info: Marbrook Lot#26 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 **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: 05 Years,�KoExpiration Residential Specifications: #Bedrooms #Bathrooms2�#People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats j � Square Footage(or Dimensions of Facility) Design Flow(GPD): W Type of Water Supply�unty/City ❑Well ❑Community Well Site Modifications/Permit Conditions: System Type LTAR Initial Repair e;/ Site Plan ¢% S f s s Environmental Health Specials t Date i i.p.11-06 JUL/23/2009/THU 14:34 Midwest Pools FAX No. 7043988708 P. 002/003 D JUL 2 3 2009 vie County Health Department ?6V :tiViROI NVIMALIL ALTH DAb"1�:COJ'�TY onmental Health Section P.O.Box 848 210 Hospital Street M. - _ F1 TY Courier#:09.40,06 !'•• Mocksville,NC 27028 �. Phone (336).751.8760 Fax:(336)-751,8786 ON-SITE WASTEWATER CERTIF ICAMN FOR DWJE)<.)GiNG (Check One) Replacementemodeling Reconnection Name: Phone Number '(,.- 9��0- QaSel (Home) Mailing Address' ILIA (Work) Detailed Directions To Sitz:901*61 ik_-4a_�:q�}_n�Me�+� R4 .4b r1 n 0+-e % AN: f .cbern �- on CW;4)A GA A,b xi'a�U-1.,.. Al Main a ae 1a'en,` C/�1,e�rfr-.� '�-t (ohm � ItL A W+'in &461��u✓P_�'"re;t n ,i erk A" 064i _An y-,411 r. M"rmk-Ilr Propc*Address: 14,9 M ,-„ Z c"4r_ �•1 .IVC 2X028 Please Fill In The Following Information About The MS'TMG Facility: Name System Installed Undar:.W Ndir /I £ la ►k � _ Type Of Facility: ' �i Date System Installed(Month/Date/Year):„ '`l" Number Of Bedrooms: Number Of People: Xs The Facility Currently Vacant? 'YesNo If Yes,For How Long? Any Known Problems? Yes No If Yes,Bxplain: Please Fill xo The Following rnfonnation About The 1VEW Facility: Type Of Facility: Number Of 13edrooms:-bl Number of Peop]c/1 Requested DT. Date Requested: signs For Environmental Health Office Use Only Approved VDisapproved Comments:��^�—R�'!!H ligor ,P `- Environmental Health Specialist *The signing of this form by the Enviromnental Health Staff is in no way intended,nor should be taken as a guarantee (extended or limited)that the oar-site wastewater system will function properly for any given period of tithe. Payment; Cash Check Money Order # Amount$ Date: Paid By: Received By: Account#: Invoice#: CAT qy F ITE EVALUATION/IMPROVEMENT PERMIT & ATC 2$ avie County Environmental Health ��� P.O.Box 848/210 Hospital Street Mocksville,NC 27028 AMEN EN past - (336)751-8760/Fax(336)751-8786 Applic n 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 ORTANT***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 f_ 1- -;�- lU)Q:1Contact Person bet I,e. J,;Z-\,/ k, Billing Address Home Phone City/State/ZIP �., �l/� Z7�Q Business Phone 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: Elite Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name Phone Number ��e7. 3&)3 Owner's Address Rol City/State/ZipAAJvc,,...e.e. /lJ C. Z w o(o Property Address h C o ��►_ City 4/ 74>c-ksi.�I Lot Size (22,to�;f� Tax PIN# 5-7C4 Z,�J'q1 q/.201 Subdivision Name(if applicable) Wc,.Lyok Section/Lot# Directions To Site:_hL,3SZ (04 L T��r C.�v �it. S� �J 4'v:so— 0 L e IV— 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 0355 Does the site contain jurisdictional wetlands? ❑Yes 25-5 Are there any easements or right-of-ways on the site? DY eso Is the site subject to approval by another public agency? eE31' s ❑No ! Will wastewater other than domestic sewage be generated? ❑Yes i IF RESIDEN E FILL OUT THE BOX BELOW #People #Bedrooms #Bathrooms 7-- Garden Tub/Whirlpool E-Yes ❑No Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW 'I Type of Facility/Business— Total Square Footage of Building #People j #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) i FOODSERVICE ONLY: #Seats Type system requested: ❑'Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: C3'C"ounty/City Water ❑New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 01TO— If yes,what type? This is to certify thate information provided on this application is true and correct to the best of my knowledge. I understand that any permits)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 owne s legal representative signature Date(s): Client Notification Date: Date EHS: j !1 I Sign given ❑Yes ❑No Account# �1173 Revised 11/06 ��� Invoice# I� CR n� Jkj %417 co 7210 ,y Ot -46 ' -- �1bi � '� � ���• - c � � T 'rh""r, '.�'�� �.._ mak: T � � ��r iqr J' ��fy � �� "� � r. .c�1 yy •. �-�.'Fp�''J ...t1' WET' � 1 � � Y9 - I�� 1. C F i 1 n rJ a r 40 op bo ir r 41 y. I 3G r�� al4 ''f K �0 „g A r "t. ��1 wr'. it _ �;� .: �•� K�' .r'1 J v `� I ^ r 2 jj _ d' ' �r;. ,- .rfid ate g \F' - t•.t -, .+ � i , r �F ;T ', _ Irk- 3" I i '�- t ift �. l�I'�'.VFC j' C' F a 4� I„• , a '14, r v. a .f y M1 1 I � ,'- - - e _. _-i-• ��.;,.�:�.t.++,lr. ':�'.�.*:`��.ham t ,�: � . � `�'- - �"�. «, JOHN CR OTTS R;D �1�I63 - .7. .. 94.1602 ,pHNcMTTS FUP3 ; � 4 7648 h FIDAD 47 4 41 175) as 1 281 ff�3i N (1. ��32 � PaD � � � � o (�,} GnB N ` (a q7 A) 7210 U 6 9.0 Ei:A 'Lc� \ O 6149 �^ o P� 6f, AZ)A) 0181 9141 1 T� CeB2a,t 1 (1.81 A M� j 0(�))163 w 313 �OOftx PcC2 CeB2 Z64 GaD co N 1 v 160 W (16.98A) 6144 L 2/)gA GnC2 l Lo GnB2 L�IL 74 1 L�52 • — 9-75 7 50 11 2'U (l 051 7 (std ` ry r9^J46 � I W (150) (233) 1 . \ Cal CO JG- MN Y N 'S J, � 1`\oQ u,' LnV d 3 Vi On Cc) in 14 r 11 , i 123' 1 � � •I77�_ 20' 104' / � , D"IE COUNTY HEALTH DEPARTMENT • Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990004173 Tax PIN/EH#: 5748-83-9141.26 Billed To: Land First Development Subdivision Info: Marbrook Lot#26 Reference Name: Rodney Bailey Location/Address: John Crotts Road-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: 1 IC) ©'7 Water Supply: On-Site Well Community Publicy Evaluation By: Auger Boring Pit / Cut FACTORS 1 2 3 4 5 6 7 Landscape position -7575- Slope S t' Slo e% (02o t HORIZON I DEPTH Texture group Consistence (7355P1 Structure eV, l { Mineralogyl i HORIZON H DEPTH Texture group ! 1 Consistence l Structure c 1 Mineralo , t HORIZON III DEPTH _ I Texture group { Consistence t Structure I' Mineralogy t HORIZON IV DEPTH l Texture groupl'! Consistence l Structure 1 I MineralogyI a SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE I CLASSIFICATION 94, k'I LONG-TERM ACCEPTANCE RATE 0t SITE CLASSIFICATION: PS EVALUATION BY: LONG-TERM ACCEPTANCE RATE: D-27S OTHER(S)PRESENT: I, REMARKS: 1�.) S I t� QU— C= C+ 2-G Q '1 L GEND i Lan s ape Position R-Ridge S -Shoulder L-Linear slope FS -Foot slope N-Nose slope y 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 MQ1St VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm .B'_'et NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky j 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) LTAR-Long-term acceptance rate-gal/day/ft2 DCHD 05/05(Bevis d) 1 ;