Bailey Downs Lot 1 Davie County Environmental Health
.P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760/Fax(336)751-8786
IMPROVEMENT PERMIT
Account #: 990005300 Tax PIN/EH#: 5880-64-8887.01 600 l tq DOW"
Billed To: Fred Bailey Subdivision Info: ' s Lot#01
Address: 493 Bailey Road Location/Address: Bailey Rd-27006
City: Advance Property Size: 10.503 Acres
Reference Name:
Proposed Facility: Residential Property
**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: EH<ew ❑Repair ❑Expansion Permit Valid for: Yeaars ❑No Expiration
Residential Specifications: #Bedrooms 1-/ #Bathrooms #People"`7 Basement❑ Basement plumbing
Non-Residential Specifications: Facility Type #People #Seats
/� Q Square Footage(or Dimensions of Facility)
Design Flow(GPD): �( U Type of Water Supply: C� ounty/City ❑Well ❑Community Well
As stated in 15A NCAC 18';� 'i
Site Modifications/Permit Conditions: accepted Systems may =+i•
System Type LTAR
Initial cc,r 7 O
Repair
Site Plan ,n
�1
S � leo r
Environmental Health Specialist Date
i.p.11-06
1� ITE EVALUATION/IMPROVEMENT PERMIT & ATC
j Davie County Environmental Health
D P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760/Fax(336)751-8786
Appl catioat' rovement Permit ❑ Authorization To Construct(ATC) ❑ Both
Type f Applicatio oA w 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 G Contact Person
Billing Address 1,4� Home Phone 9y' 'ted"�O 9
City/State/ZIP o/ G.� C 7 OCP 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: 2 Site Plan elat(to scale)
(Permit is.valid fo 60 mont}�s with site plan no expiration with complete plat.)
Owner's Name FF� 7;i g d-Pr i�� Phone Number
Owner's Address City/SMAI&
p
Property Address Al City �
Lot Size /Q. 50 3 Tax PIN# ate _99 P
Subdivision Name(if applicable) Secti n/Lot#
Direction's To Site: 6V � R" l- 9,V/
a Ad,P S e — 're 5 /J ViD z/ Kit
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 CKo
Does the site contain jurisdictional wetlands? ❑Yes AIo
Are there any easements or right-of-ways on the site? fl'i'es ❑No Pm aver :a�
Is the site subject to approval by another public agency? ❑Yes EKo
Will wastewater other than domestic sewage be generated? Dyes
IF RESIDENCE FILL OUT THE BOX BELOW
#People #Bedrooms #Bathrooms Garden Tub/Whirlpool DY-e-s' ❑No
Basement: es ❑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:. conventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: /County/City Water ❑ New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No
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 pennit(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 riles.
I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging
r staking the house/facili proposed well location and the location of any other amenities.
Site Revisit Charge
Property o is or owner's legal representative signature
Date(s):
Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account# L"J �J�0
Revised 11/06 Invoice#
' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990005300 Tax PIN/EH#: 5880-64-8887.01
Billed To: Fred Bailey Subdivision Info: Fred Bailey Properties Lot#1.
Reference Name: Location/Address: Bailey Rd-27006
Proposed Facility: Residential Property Property Size: 9.097 Date Evaluated:
Water Supply- On-Site Well �J Community Public
Evaluation By: Auger Boring ��} Pit Cut
FACTORS 1 21B 3 C 4 5 6 7
Landscape position
Slope%
HORIZON I DEPTH W —
Texture groupj G C. 5�
!> - Consistence f -
Structure 17 56 k le
Mineralogyb K
HORIZON II DEPTH =
TexturegroupQ 5 LL
Consistence 15d
Structure I
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogyt
HORIZON IV DEPTH vw
Texture group
Consistence p t
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE D. 27 Q. 14
SITE CLASSIFICATION:,` EVALUATION BY:
LONG-TERM ACCEPTANCE RATE:. 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 VFl-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)
TTAR -Lnno-term arre.ntanrP rate- oal/riau/ft) TIVnTTn AC Inc m__.e_-��
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I IR N G AREA= 10.503 AC.
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PLACED PLACED $IRO '
O N PLACED IRON • '4S•.V
C4 IRON S REHAB C3 S
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