Bailey Downs Lot 2 { Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760/Fax(336)751-8786
IMPROVEMENT PERMIT
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Account #: 990005300 Tax PIN/EH#: 5880-64-8887.02 &36V 60WOS
Billed To: Fred Bailey Subdivision Info: Lot#02
Address: 493 Bailey Road Location/Address: Bailey Rd-27006
City: Advance Property Size: 9.097 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 thiroffice 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: El�ew ❑Repair ❑Expansion Permit Valid for: C115'Years ❑No Expiration
Residential Specifications: #Bedrooms #Bathrooms#People Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
q�oSquare Footage(or Dimensions of Facility)
Desi a Flow GPD : Type of Water Supply: o
/Cit3❑Well ❑Community Well
p i1 QQ c•:le heualsSS Paldaae
Site Modifications/Permit Conditions: (S –c-96T'V9T OVON 1d9T ul pa;els sV N
N
4
System T)Te LTAR
Initial
Repair
Site Plan 13 JL J
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J-7 h� i —
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Environmental Health Specialist Date — —� 9
i.p.11-06 i
APPL ITE EVALUATION/IMPROVEMENT PERMIT & ATC
Savie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
Pik (336)751-8760/Fax(336)751-8786
Applic tion r: on vement Permit ❑ Authorization To Construct(ATC) ❑ Both
Type o pplicatiby N. I in ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IM TANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATIONS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
e
Name to be Billed
1' L' Contact Person � 5
Billiiig Address Home Phone
City/State/ZIP e— MC, 2 70 O 61 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: ®'Site Plan Pflat(to scale)
(Permit is-valid fo 60 mons with site plan no expiration with complete plat.)
Owner's Name ii. d-oY SAi Phone Number
Owner's Address City/Stat /Zip
Property Address ei-/_ City W/L& 0-
Lot Size_ l 'Tax PIN#_ 5 d-t q•��_7
Subdivision Name(if applicable) Secti n/Lot# �i
Directio To Site. — -C:i± 75 r1v , le-t
e — 5 /J �� ?/ i
If the answer to any of the following questions is"yes",supporting documentation must be attac ed.
Are there any existing wastewater systems on the site? Dyes EKo
Does the site contain jurisdictional wetlands? Dyes 2No
Are there any easements or right-of-ways on the site? Eyes ❑No Pa a-, :+Ye—
Is the site subject to approval by another public agency? Dyes EKO
Will wastewater other than domestic sewage be generated? Dyes
IF RESIDEN!gg FILL OUT THE BOX B OW
#People #Bedrooms #Bathrooms /moi Garden Tub/Whirlpool ❑fie ❑No
Basement: es ❑No Basement Plumbing: Dyes ❑No
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of FacilityBtisiness 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:. I<onventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: Q"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 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 detemiine 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 own/i's or owner's legal representative signature
Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account#
Revised 11/06 Invoice#
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990005300 Tax PIN/EH#: 5880-64-8887.02
Billed To: Fred Bailey Subdivision Info: Fred Bailey Properties Lot#02
Reference Name: Location/Address: Bailey Rd-27006
Proposed Facility: Residential Property Property Size: 10.503 Acres Date Evaluated: y 7
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit ef:::� Cut
FACTORS 1 228 3�L& 4 5 6 7
Landscape position L
Slope %
HORIZON I DEPTH - '1
Texture group
Consistence p `!,-
Structure /
Mineralogy
Y
HORIZON H DEPTH
Texture group ZZ
5 G!,
Consistence 1#0 Pn f '
Structure 'S L2&x J4 V49
Mineralo 7
HORIZON III DEPTH
Texture group 5
Consistence
Structure
Mineralogy ^t/r
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS �
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE3.-L). 7jr
SITE CLASSIFICATION: EVALUATION BY: 11117KJ'��::�2
LONG-TERM ACCEPTANCE RATE: 5�' )L 2 OTHER(S)PRESENT:
REMARKS: `e V1 C)
LE ND
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
3
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)
ITAR -Irmo-term arrPntnnrP rat,-- oaUiiau/ft7 m__.--X'
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AREA= 9.205 AC.
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AREA= 9.097 AC.
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