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149 Elberon Ct Lot 11 Davie County Environmental Health P.O.Box 848/210 Hospital Street P Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 990004173 Tax PIN/EH#: 5748-83-9141.11 Billed To: Land First Development Subdivision Info: Marbrook Lot# 11 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: Z-N-ew ❑Repair ❑Expansion Permit Valid for: 05 Years,,8<o Expiration Residential Specifications: #Bedrooms L4 #Bathrooms2'�People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) DesignFlow(GPD): �fJ�/ Type of Water Supply:Xounty/City ❑Well ❑Community Well Site Modifications/Permit Conditions: System Type LTAR Initial 01---2 Repair o. Site Plan lr �n�r•lrAmL� � � Environmental Health Specialist Date i.p.11-06 ICAT 01 F ITE EVALUATION/IMPROVEMENT PERMIT & ATC avie County Environmental Health P.O.Box 848/210 Hospital Street P�!�� Mocksville,NC 27028 . (336)751-8760/Fax(336)751-8786 Applic n or: t 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 ***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 (__c-"s� 1- -;'E- l7Q ise �, 0,�-w� Contact Person Billing Address P-A Ht-, y '?J i 6"-I h Home Phone City/State/ZIP 14&&- 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: ite Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat:) Owner's Name 6.-.*Ql Phone Number �� •-� C� Owner's Address City/State/Zip l ic,rc /U C. Z 2,20(.) Property Address__ .I L►c•� C J' ;��_ City. Lot Size c22- f) Tax PIN# -5740k 'C?/ f,/1 Subdivision Name(if applicable) k Section/Lot# Directions To Site: HL-�V (a(4 LIF '� Tv 1^►� C�v ��. S �,tl ;s `e 2�' 'L 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 0-No- Does -No Does the site contain jurisdictional wetlands? ❑Yes 011-oo Are there any easements or right-of-ways on the site? ❑Yews �o� Is the site subject to approval by another public agency? ePll' s ❑No Will wastewater other than domestic sewage be generated? DYes la1q`6 IF RESIDEN E FILL OUT THE BOX BELOW #People #Bedrooms #Bathrooms ' 7- Garden Tub/Whirlpool Cis ❑No Basement: ❑Yes ❑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: CfC-onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: 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 3-ITo— If yes,w//h//•.jat type? p)y Was This is to certify that1he 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. 1 Site Revisit Charge Property er' or ownebfs legal representative signature Date(s): l�- ;2 Client Notification Date: Date EHS: Sign given [I Yes ❑No Account# 7/6� Revised 11/06 Invoice# S 1 11 �s:¢ 4763 D� 1�,1 a 1 � 4 RAD 15631 w Fj CID a - N y +�'� L d!-q ' 4'y r 'y' y� .l + ' #-.y= F 7210 . 96 fQA . yy.... 6149 #F,: �i' " ... 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LONG-TERM ACCEPTANCE RATE: '3 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 M4LSL 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 r k 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 LYQtes . 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 f Classification-S(suitable),PS(provisionally suitable),U(unsuitable) LTAR-Long-term acceptance rate-gal/day/ft2 DCHD 05105(Revised)