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154 Elberon Ct Lot 6 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#: 5748-83-9141.06 Billed To: Land First Development Subdivision Info: Marbrook Lot#06 Address: 228 NC Hwy 801 North LocationlAddress: 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 Expiration Residential Specifications: #Bedrooms #Bathrooms '�#People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People . #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):��� Type of Water Supplyounty/City ❑Well ❑Community Well Site Modifications/Permit Conditions: System Type LTAR Initial ©• Repair . Z Site Plan i k i ,� y ,m �� .�'.t 11 � �T''•dy. �I Ala.- -r Environmental Health Special' Date i.p.11-06 10 i , I q4- IINN . ' \ If za- -63 J;a. r Y- M I - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account M 990004173 Tax PIN/EH#: 5748-83-9141.06 Billed To: Land First Development Subdivision Info: Marbrook Lot#06 Reference Name: Rodney Bailey Location/Address: John Crotts Road-270281 Proposed Facility: Residence Property Size: see map Date Evaluated: 1 t I o1 Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Sloe% HORIZON I DEPTH p p 2 Texture groupG S. Consistence t^r-SP SP Structure k t Mineralogy HORIZON H DEPTH Texture group ` r_+bc SSC Consistence S S r S Structure i Mineralogy HORIZON 1111 DEPTH - 4 Texture group 540 S;t Sl Consistence mg KPI Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS ^- RESTRICTIVE HORIZON �) SAPROLITE CLASSIFICATION S P 5 LONG-TERM ACCEPTANCE RATE C ,Z?,5 Z %•Z74f SITE CLASSIFICATION: PS EVALUATION BY: LONG-TERM ACCEPTANCE RATE: �'2� OTHER(S)PRESENT: REMARKS: LEGEND L nndccape 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 ONSISTEN . , 1?3Qist 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 1;1,2:1,Mixed ]votes 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) JOHN CROTTS RD 4743 - 754830TS WAD SR 1602 - fJH NC WT ,�• a 4p i= '146; - 1 ® - 1 � N a17 ��A, PaD s °A 3z Gn B Cn4 9141 1 0181 jp CeB2 / � 1081' y�63 00 \� PcC2 �- T364 GaD CeB2 (r5 00 160 Cry —,1 (16 ym) 1 b144 GnC2 l Lo GnB2 L L 74 \ ti 76179543 nc j u> �1 ICAT�Q F ITE EVALUATION/IMPROVEMENT PERMIT & ATC avie County Environmental Health P.O.Box 848/210 Hospital Street `MP�HEALZH Mocksville NC 27028 ILI' (336)751-8760/Fax(336)751-8786 f. t. 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 n Name to be Billed Contact Person Billing Address Home Phone City/State/ZIP 1,45&f..l4 �4 �(L� 2�-7L,DJb Business Phone (S - Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Comers Flagged NOTE: A survey plat or site plan must accompany this application. Included: Er§ite Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name „ ""i Phone Number ��� a �3 Owner's Address Rol 1^ City/State/ZiL/c,. e. Property Address G,r� C.�a �(t1_ City_/110c �fvil/Q Lot Size x'22- Tax PIN# 574($Fkgg1g1,0(0 Subdivision Name(if applicable) r k Section/Lot# Directions To Site: HL,.�V (a Lf 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 ON-6 Does the site contain jurisdictional wetlands? ❑Yes ON—o Are there any easements or right-of-ways on the site? ❑Yes o Is the site subject to approval by another public agency? es ❑No Will wastewater other than domestic sewage be generated? ❑Yes Bl o� IF RESIDEN E FILL OUT THE BOX BELOW #People #Bedrooms *4V #Bathrooms 7,,J I-Z., Garden Tub/Whirlpool Byes ❑No Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No &A 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: CrConventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: D- 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-N If yes,what type? Wks Ccs nd 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. `144"1 -13"� Property er' or owne legal representative signature Site Revisit Charge 4x Date(s): �Zl— ;2 Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# Revised 11/06 Invoice# OHN C R OTT t. �:o, 47G3 d� I call i - � +!� W J w�J�_• 1 Ay� �� � -. a .- - ... '.'J7) � �! O 00 �l"�•,.�''t'y:-'k -�� a. i !!� '1 (,1.v7 A) _r2 10 ° .114 ), T• r (. ` i 6149 ,�..'' i• - C�,a.+iY �•r •yz ^i'P.::S�tr �. �±t z t1 .� t �a~a r k(�Ka9•�"• +, r'.,,k -,�J�, c H 'a`�' - y a:•J�7"d f .. i ,� . s,,, ,.• � �h r g ka� l'f' x'� S 4j ti`��i+•���f �� y. r .'a a ,4�`; .. i �. ���j .+ wr' ,"�( ���- c�' Yco *'`q E r cart � tO r a r Y 1 M+ p •d lr; ' ^ � Nj Y.j A�°" , ! 4,Yb:. ,' , Y1 'r ;;,,�-&+ .<, � , ..,ia •�(r. RBA) edt �,• '- �r"t:s�^.A y: !. ." 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