104 Elberon Ct Lot 1 I
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#: 5748-83-9141.01
Billed To: Land First Development Subdivision Info: Marbrook Lot#01
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.
PemutType: ew ❑Repair ❑Expansion Pennit Valid for: 0 Years A Expiration
Residential Specifications: #Bedrooms 3 #Bathrooms2,) #People Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): 3Co�`7 Type of Water Supply: P4tb***unty/City ❑Well ❑Community Well
Site Modifications/Permit Conditions:
System Type LTAR
Initial
Repair
Site Plan Z� 1, =^ .✓' - - +e- —
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Environmental Health Specialistto 7 to L07
i.p.11-06
n 1
D ICATg1 F ITE EVALUATION/IMPROVEMENT PERMIT & ATC
7$ avie County Environmental Health
P.O.Box 848/210 Hospital Street
�(P� Mocksville,NC 27028
W, ���� (336)751-8760/Fax(336)751-8786
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 _ IF:,-&A- JDaye le, O Contact Person
Billing Address �L,�? Ho X Vy I S&V-fh Home Phone
City/State/ZIP 14&6,4 / 2-1.ag 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: Etite Plan ❑Plat(to scale)
(Permit is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name rL l �--e.., Phone Number -38d3
Owner's Address o/ City/State/Zi6-JC. Z 763000f
Property Address 4�(t1_ City 4,10(-krc,i6/Q
Lot Size C52e-fYl f'/ Tax PIN# -574 0OL-91 il/,01
Subdivision Name(if applicable) k Section/Lot#
Directions To Site: H L.s V (p(4 C 'A— 7'v k n Ce,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 ❑ -5
Does the site contain jurisdictional wetlands? []Yes Engo-
Are there any easements or right-of-ways on the site? ❑Yeso
Is the site subject to approval by another public agency? e0Y s ❑No
Will wastewater other than domestic sewage be generated? / ❑Yes Bl oo -
IF RESIDEN E FILL OUT THE BOX BELOW `S/r��� u �^ 1 3 �adS
#People #Bedrooms 'q #Bathrooms 211 Garden Tub/Whirlpool [mss ❑No
Basement: ❑ es ❑No Basement Plumbing: ❑Yes ❑No ff
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: DU6nventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: 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 Cho
If yes,what type?
009
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'ievocation 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
Property er' or owne s legal representative signature
Date(s):
// Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No /i Account#
Revised 11/06 Invoice#
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L LIP.L Z UTRECT10N i)ISTANCE�� '
i t i I L-1 S 89*31,19,
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INEORMATIQN
Account #: 990004173 Tax PIN/EH#: 5748-83-9141.01
Billed To: Land First Development Subdivision Info: Marbrook Lot#01 1
Reference Name: Rodney Bailey Location/Address: John Crotts Road-270 8
Proposed Facility: Residence Property Size: see map Date Evaluated: 1101co
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position L
Slope% L4 2o H 2ot
HORIZON I DEPTH C>- D"17-
Texture
Texture rou IL CL_ I
Consistence -r -r SSW Ii
Structure !
Mineralogy se , - F
HORIZON H DEPTH r 12--2
Texture group C_ G
Consistence r F;Se
Structure S k
Mineralogy
HORIZON III DEPTH
Texture groupC�
Consistence rS H�S
Structure L k
Mineralogy
HORIZON IV DEPTH Lv !
Texture group ti S r 4$
Consistence Fry 6
Structure
Mineralogy
SOIL WETNESS — --
RESTRICTIVE HORIZON
SAPROLITE U
CLASSIFICATION S S
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS: I&VC, ,�(� C k�Gn 1 C- �=y Ck
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 SI-Silt
SICL ' Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
CON4IST .N
Moist
VFR-Very friable FR-Friable FI-Firm VFI Very firm EFI-Extremely firm
33'et
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
]motes
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)