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151 Marbrook Dr Lot 25 DAVIE COUNTY ENVIRONMENTAL HEALTH r► --� P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT /r 6-1 10A 6Po Account #:' 990004479 Tax PIN/EH#: 5758-02-4400 Billed To: B.W. Phibbs Construction Subdivision Info: Marbrook Lot#25 Reference Name: Location/Address: Marbrook Dr-27028 Proposed Facility: Residence Property Size: 239x125x125 ATC Number: 4788 **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. ��� / Q� � Odd ` System Type. t S.T.Manufacturer :5M 6k Tank Date Tank Size Pump Tank Sizz System Installed By6(( i/h Q'A E.H. Specialist: UA66 Date: 117' / 06 \ 5, D I v � � I L� 1 Jg , a DCHD 11/06(Revised) p _ r DAVIE COUNTY ENVIRONMENTAL HEALTH �d(�� P.O.Box 848/210 Hospital Street Ili l Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990004479 Tax PIN/EH#: 5758-02-4400 Billed To: B.W. Phibbs Construction Subdivision Info: Marbrook Lot#25 -Reference Name: Location/Address: Marbrook Dr-27028 Proposed Facility: Residence Property Size: 239x125x125 ATC Number: 4788 r Site Type: slew ❑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 #Bathroomsz People Basement❑ Basement plumbing❑ Non=Residential Specifications: Facility Type #People #Seats (1 Square Footage(or Dimensions of Facility) Lot Size-rM0 Type of Water Supplyrunty/City ❑Well ❑CommunityWell System Specifications: Design Wastewater Flo_w(GPD) c3t0C)Tank Size AL.Pump Tank GAL. Trench Width Max.Trench Deptk?V Depth? Rock'Deep/t�h Z Linear Ft. q qo Site Modifications/Conditions/Other: 0,3 Contact the Davie County Environmental Health Section for final inspection of this system between :30-9:30a.m.on the day of installation. Telephone#(336)751-8760. As ststed in 15A NCAC 18A.i9 5 5riccepted Systems may 8180 be a eal Y4. c � v i 32)) —M r.-t•�t7 � i Eavironmental Health Specialist Date: a DCHD 11/06(Revised) E APPLICATION SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 NOV 2 1 2001_ (336)751-8760/Fax(33 751-8786 plication For: 0 Site n/Im rovement Permit Authorization To Construct(ATC) ❑ Both e op IE CAIINZY QITpINC0tystem Repair to Existing System ❑Expansion/Modification of Existing System or Facility V ** T***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 !?) ; W, P�; 6 b S Con Contact Person (In S; 1 La. R; b6 < f Billing Address _-�) yp V;c n n a Q0z i r-(7 er.l. Home Phone o lad -OG �y I City/State/ZIP PSC)ffi'ow n n . C, a 7o 40 Business Phone 3 LIS - 10;;t s I I Name on Permit/ATC if Different than Above Mailing Address City/State/Zip I PROPERTY INFORMATION *Date House/Facility Corners Flagged -O 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.) Owner's Name aS; I (,I, 9JJ',66S Phone Number 3X13-ioas Owner's Address_51 k0 lj,C.n nu - bn 7 i c IZ V0. City/State/Zip 1�,Pfc,McrL A h,c. ,2)o ct O� Property Address City Lot Size S ( 'da Tax PIN# Oa Subdivision Name(if applicable) - /L Se do o # Directions To Site: CZJ, r Q i 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 Flo Does the site contain jurisdictional wetlands? ❑Yes &No Are there any easements or right-of-ways on the site? ❑Yes GlNo Is the site subject to approval by another public agency? ❑Yes ENo Will wastewater other than domestic sewage be generated? ❑Yes Flo IF RESIDENCE FILL OUT THE BOX BELOW. #People #Bedrooms - , #Bathrooms A Garden Tub/Whirlpool es ❑No Basement: ❑Yes PNo Basement Plumbing: ❑Yes &No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People I #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested SLonventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: B'tounty/City Water ❑ New Well ❑Existing Well ❑ Community Well P Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes N-X-0 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 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 comers and locating and flagging or staking the house/facility location,proposed well location and the location of any other amenities. L3 O' ("� �%'-�� Site Revisit Charge Property owner's or owner's legal representative signature Date(s): i 1 ',�I "0 7 Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# 7 Revised 11/06 Invoice# /47,01 f { I 1 1 i CAS 1 p i 'k Q ICAaTIOI F ITE EVALUATION/IMPROVEMENT PERMIT & ATC avie County Environmental Health P.O.Box 848/210 Hospital Street �MEN�P\HFA��N Mocksville NC 27028 ENv\R�� p�,,� ' V)N _ (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 ***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_L�, �� 1-:.-;�- l7�gee 0 0 '� Contact Person tsC bd ne,-- Billing Address__�L,�$ fJw X FJ J Home Phone City/State/ZIP 14&&.C4 �4 4. 2— Business Phone 0 --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: Ertlite Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name Phone Number Owner's Address of City/State/Zip�7��c,��e /V,C. 2 wok Property Address , �,(n h C fa "k/,/- City_`lloc-AZdI/V Lot Size C5,ee,/n" Tax PIN# 7C4 agi?l q/,25 Subdivision Name(if applicable) k Section/Lot# 2� Directions To Site: H L.-�V (0(4 L=- If 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 DN-o Does the site contain jurisdictional wetlands? ❑Yes 01q Are there any easements or right-of-ways on the site? ❑Yes o Is the site subject to approval by another public agency? eHY s ❑No Will wastewater other than domestic sewage be generated? ❑Yes QNo IF RESIDEN E FILL OUT THE BOX BELOW #People #Bedrooms -T #Bathrooms 71 Garden Tub/Whirlpool (des ❑No - Basement: ❑ es ❑No Basement Plumbing: ❑Yes ❑No 41,14 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: L7Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: a County/City Water ❑ New Well Misting Well ❑ Community Well 1 Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes C-N If yes,what type? f I lti2 i.v`s (,a nd This is to certify thae 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 PropertyKM er' or owne legal representative signature Date(s): ��- ;2 yLo Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# Z//73 Revised 11/06 ��� Invoice# CROTTS r u - A � t $C +w'W '- .s t s•` s - ~w �' ii +� J (631 �•� ;° ?S� ��._ �" d�!' T � .�ai � 't" � � •fie � ,.. H �'; �, .i � •ti ,. . 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' U .'£h' i SG• LR6";Jnr }.? r • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION � Account M 990004173 Tax PIN/EH#: 5748-83-9141.25 Billed To: Land First Development Subdivision Info: Marbrook Lot#25 Reference Name: Rodney Bailey Location/Address: John Crotts Road-2 Proposed Facility: Residence Property Size: see map Date Evaluated: lok? Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope% 426 �j HORIZON I DEPTH 0-00 0 Texture group Consistence Structure I Mineralogy5�. HORIZON H DEPTH I Texture group "G� i Consistence G; N41 Structure _ f Mineralogyl HORIZON III DEPTH Ltlr Texture group ST A Consistence E Structure L I Mineralogy HORIZON IV DEPTH tl Texture groupi Consistence I Structure Mineralogy SOIL WETNESS -- t RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION 15 LONG-TERM ACCEPTANCE RATE 19-TniC SITE CLASSIFICATION: S EVALUATION BY- LONG-TERM ACCEPTANCE RATE: 01,7J OTHER(S)PRESENT: REMARKS: I LEGEND I' 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 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 pp I' Mineralogy ' 1:1,2:1,Mixed lYot� 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 Account #: 990004173 Tax PIN/EH#: 5748-83-9141.25 Billed To: Land First Development Subdivision Info: Marbrook Lot#25 Address: 228 NC Hwy 801 North Location/Address: John Crotts Road-2, 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 X�lo Expiration Residential Specifications: #Bedrooms 4 #Bathrooms2-S #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):L Type of Water Supply:,,216ounty/City ❑Well ❑Community Well Site Modifications/Permit Conditions: System Type LTAR Initial Repair Site Plan l Z %0 p { -0 >? ro ` 7' I 71 m V F S -4- Environmental Health Specialist Date d7 i.p.l l-06