150 Marbrook Dr Lot 15 i
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760 Fax#(336)751-8786
OPERATION PERMITzii-!
6-6
Account M 990004119 Tax PIN/EH M 5748-88-9141.15
Billed To: M &M Construction Subdivision Info: Marbrook Lot# 15
Reference Name: Location/Address: John Crotts Road-27028
Proposed Facility: Residence Property Size: 209x232x131x
ATC Number: 4716
**NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC has been installed
in compliance with Article I 1 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. CoSystem Type: S.T.Manufacturer�"g Tank Date C '��1 Tank Size Lo CIO
Pump Tank Size •J
� 1 ���� ��
1 2lv
System Installed By: E.H.Special st:
' 3 Wroom
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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 #: 990004119 Tax PIN/EH#: 5748-88-9141.15
Billed To: M &M Construction Subdivision Info: Marbrook Lot# 15
Reference Name: Location/Address: John Crotts Road-27028
"
Proposed Facility: Residence Property Size: 209x232x131x
ATC Number: 4716
Site Type: Xw ❑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 #Bathrooms 2,5�#People Basement❑ Basement plumbing❑
Non=Residential Specifications: Facility Type #People #Seats
((11 Square Footage(or Dimensions of Facility)
Lot Size 3I2 `r"r1 Type of Water Supply: �C;ounty/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow(GPD) c�:;; O Tank Size GAL.Pump Tank GAL.
'1 " t
Trench Width Max.Trench Depths Rock Depth W A Linear Ft. 330
Site Modifications/Conditions/Other: L= L= > kf4D- .;0 S
Contact t unty Environmental Health Sectio for final inspection of this system between
8:30—9:30a.m.on the day of installation. ele hone#(336)751-8760.
U`a �
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Gtr' �
E
Environmental Health Specialist Date: &E5J07
DCHD 11/06(Revised)
i
AP D c` : DDD-DDD-QpgDg Piing 1
p 1-. s41t arvie•oouttt3-•nvhfartth 336 751 8786 p.2
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JUN APP allW1U FOR iITE EIIALUAT10N/IMfR0VFMEN'f PERlv11'f-&ATC
style COlsnty Health Department
tt�tENZPL Fnviroximental Meakh- eetioi
P.O.Box 84010 Bosp w Strict
M9d(&vWseNC-.27WJ
/ (336)7S1-8760/FJts(336)7;;1-8786
Appliuuonfur. (;iUsrraluulmrinJpfareaua�r-Pamrif tfAuttwizauw,ToCauructlATC) N.
ass114P01qTAIYl---TwSAlT11CA7R0NCNNOTBBPROCb3SEDUFl.>; ALL OFTie REgl;mFn
W0XMA,TM l&pR0ylVyD-Rsl.;to tbo 1NPORWrION BULLETIN for iroir=1fe.a,
APPLICANT INXORMATIt7pJ-.. -
NLw to be V� r
nPteon •-
B$fi A - � -
9, �Cowcl 1lotncP
CirYlStaee/Z��1eC1(
bears:'as PenniVATC iFDiffvvw thsi Above
Mailing Add�ou
PR0PIR7'YOYFORMA77ON
NOTE:.A etuerAy.plat a aNeplaa tKetJtt�sq etas appltcatmn. '--- __.
elle St A(teaa is valid lot 60 moaduc»,h site
epil m no expiration Milk conrlete#let.)
g I1att � �`� +L--Cm! V111lam_Tall P1NN
nianactio7o Sire 3caiwl.om lot
Sias- -
hate liouae/Faeilityco�ners FlagRcd_��j-- ""-• ••--• �•----
lf Ibe sneerer b.ay of Ille tullorvina gnauoea n-Yes'xapyormtg tDautttemathln tMM be attached,
Art dtere sty eanft w.119w,ne-systc'm on rbe site? rives wtk
LIM rhe site eonnen jtttisdictior al wt l"47 1 JYas kNo
Are ftso any earatrttta or r1*+&jf-wttyr qe Ilio oteT• QYa I.tlOa
lathe"'10
subject ro appruval by:,aotber public ascocy? U Yes laevo
wig wastewater odw thea daeto de+wwwse be reswkd? Utes tad
IF USIUENCE FILL OUT nM-F•OX BBMW _ `
a<Pmple. X Bedronrr k @at _ trardcli I u_lt/W1Jitlpool as 04.
llavernentTEYec 1740 Basentew Plumbing: tMc, f
IF NON•RESIDEN(M.FELLOW"IMBOX BELOIK-
Type of Facifiry/Aasineu, Total Square Foot=of Auildittg p Peopk
N Sirtl�_ M CtJrttettotlea�` x Shower.. /ttlflrtata E0stODSE RWVeICtsIONLY.
yltmtas:pu__ .y) (.ech documrntaliVo ofaimia Iolity_w
oler cunaumptinn)
_
Type systcm rwgjwsted'Voonvrationel 1'Ampted 111m radve UAltanar ve t l(Mbsr
water$apply Type:{Ko ptfy/C4 Wwrr t t New wall uExistin,}weN u Community wen
W you anticipate additw m m rrpseyio,ts•(the facility this sygtm u sets&ded rn seA77 1-1 V"'
It yes•what typtfl
Ibis i.to t eerily that etre irttutmadoa prt,vi led atbia spp6eaeion.is ase ttml ctrrect b the best of ray katovticd6r:-,understand dtat-
say ptxrrtit(s;ter ATC'1.j letJed tot icsfta at o subject to stup.ns,ou ur rcvacaona sf the cite n steered.the irslrrdeA uu clangs or if
W infomatitm submimil in this applieamit is rawftrd to changed /tutdtntun l rlwr last rwps.sJ,I.IEv all eliarrra incurred
born this arphemloa. l kmby grace eiglg,{eoaY to theArWerned Reprftm tivc of dte lhvia Cttumy Halthlkpatm u to
11at ia
ry and cpccdor M drftnrmr eowhaace wtth appliccbie IM ruler on due above tl robed prolwmy located in
"T by
0 otos r,epte to stive Rr natore-
Site Revisit O.rgc
Chem Notification Vale;
Dole- F.IIS-.
Sign given {tYe.t1N0 _ Acc~a
Rsvkcd-2M6 Im oice s
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JUL- )-4,,20Q5:'06.53. Nt:SG'LTS'CAL➢WS� 336 751 87862
06/25/2007 01:26 9988780 PAGE 02/,/25/2007 01:26 9988780
APR 17,2006 07:52 000-000-00000Pa90 1 .APR 17,200607:52 000-000-00000 page 2
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NOTE
THIS IS NOT A BOUNDARY SURVEY BY RONALD L. OXENDINE SURVI:YUICLO
�tJ
TK BOUNDARY WAS DRAWN FROM INFORMATION OE AINED FROM OTHMS. (w ice, -
MDRAMft1NC 15 TO BE USM ONLY FM RFVEtYM (DRY TO O87TSiN-A ta
�} tv Fp
MIMING PERMIT,THE PROP05M HOUSE LOCATION MAY VERY SOME WHEN �� t• �~
AN ACTUAL BOUNDARY SURVEY IS DONE BY RONALD L OXENDINE SURVUNG.
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LA=6.87* R=275,00'
MaBRQQK DRIVE 1489156'06'Vssr (�+as�)
(50• PUBLIC R/W) J
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A hWS€IAYaUTWORXSHM FOR
M & M CONSTRUCTION, INC.-
LECIEND Lot 15 IN"MARBROOX SUBDIVISION"
lylare•ATV LING --
...__ ADt TWAT Uo ` TAX MAP TOWNSIiIP f slow DATE
Nit N[M.r AT 1W rlre COUNTY _STATE
Ear tx�.r w ua�r vE I OCKID I DAME N.C. 32 UNE I qc DZ 7
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1SCALE-_
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ICAT�q F ITE EVALUATION/IMPROVEMENT PERMIT & ATC
O \ 12$ `� avie County Environmental Health
P.O.Box 848/210 Hospital Street
NRD�ME�p��'FA��N Mocksville,NC 27028
(336)751-8760/Fax(336)751-8786
0
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
***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 LC-�� I :r;�- (�Q�,ie 0,..,,-}' Contact PersoneV
Billing Address 6",'Y-h Home Phone
City/State/ZIP / 4 -, 2— Business Phone cj6 --2
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: Blite Plan ❑Plat(to scale)
(Permit is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name 1 «.-rz ., Phone Number
Owner's Address go / Sv t^ City/State/Zip �7c�i.c,rL e. /U C. Z w o<, 4
Property Address " : �G,rkx C.� o ,�1_ City Yli1v �-SL.ii
Lot Size c>oe-% 0:40 —TTax PIN#
Subdivision Name(if applicable) .-to r-o k Section/Lot#
Directions To Site: H t,s SZ (p(4 L 14,
C
If the answer to any of the following questions is"yes",supporting documentation must be attached. j
Are there any existing wastewater systems on the site? ❑Yes DN-o
Does the site contain jurisdictional wetlands? ❑Yes Eil o
Are there any easements or right-of-ways on the site? ❑Yes o
Is the site subject to approval by another public agency? Eries ❑No
Will wastewater other than domestic sewage be generated? ❑Yes Dlgo
IF RESIDENCE FILL OUT THE BOX BELOW
#People #Bedrooms _ #Bathrooms t' Z. Garden Tub/Whirlpool ids ❑No
Basement: ❑Yes ❑No Basement Plumbing: ❑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: C3Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: C3-ounty/City Water ❑New Well ❑Existing Well ❑rCommunity Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes G-No
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 comers 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 legal representative signature
Date(s)`.
,2 Client Notification Date:
Date EHS:
i
Sign given ❑Yes ❑No n Account# 40-3
Revised.11/06 Invoice#
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r DAVIE COUNTY HEALTH DEPARTMENT
O i.
' Environmental Health Section
Soil/Site Evaluation r
APPLICANT INFORMATION PROPERTY INFORMATION
Account M 990004173 Tax PIN/EH M 5748-83-9141.15
Billed To: Land First Development Subdivision Info: Marbrook Lot#15
Reference Name: Rodney Bailey Location/Address: John Crotts Road-27028
Proposed Facility: Residence Property Size: see map Date Evaluated:
y
I
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7,
Landscape position 1
Slope% 5
HORIZON I DEPTH p z>611
Texture groupCL_ C
Consistence
Structure
Mineralogy O �.. k
HORIZON II DEPTH - 72-
Texture
LTexture groupC. F
Consistence
Structure 1s
Mineralo SO- L
HORIZON III DEPTH -4S- 2Z
Texture group •1
ConsistenceQ `
Structure S!
Mineralogy $v f
HORIZON IV DEPTH I
Texture groupa
Consistence (' l
Structure
MineralogyE
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE — —
CLASSIFICATION Q�
LONG-TERM ACCEPTANCE RATE 1 0.2-75 .2 '- P
SITE CLASSIFICATION: e EVALUATION BY: C4-K`'`•'�
LONG-TERM ACCEPTANCE RATE: 0• 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 Sl-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
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 05105(Revised)
+ Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760/Fax(336)751-8786
IMPROVEMENT PERMIT l
Account #: 990004173 Tax PIN/EH#: 5748-83-9141.15 f
Billed To: Land First Development Subdivision Info: Marbrook Lot# 15
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: ❑5 Years ,B7!lo Expiration
Residential Specifications: #Bedrooms #Bathrooms2,6#People Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): Type of Water Supply: ounty/City ❑Well ❑Community Well
Site Modifications/Permit Conditions: POOP -EX 0►Z%Z0 t- k YW'-4R
Systerrj,,TypQ LTAR
Initial Z
Repair
Site Plan J t r
x 1Ni T
.Environmental Health Specialist Date 07
i.p.11-06