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111 Elberon Ct Lot 14 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street �y/3�6� Mocksville,NC 27028 / `( (336)751-8760 Fax#(336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990002706 Tax PIN/EH#: 5748-83-9141.14 Billed To: Jeff Hayes Subdivision Info: Marbrook Lot# 14 Reference Name: Location/Address: Proposed Facility: Residence_ Property Size: see map ATC Number: 4686 Site Type:/eNew ❑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 #Bathrooms #People . Basement❑ Basement plumbing2r, Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size &o Z72 Type of Water Supply: 2eounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD) -Z-4Co Tank Size leco GAL.Pump Tank GAL. Trench Width 7R;' Max.Trench Depth Rock Depth 4N,A Linear Ft. Site Modifications/Conditions/Other: W--u2VZP OFF Contact the Davie County Environmental Health Section for final inspection of this system between Es 1 T-8:30--9:30a.m.on the day of installation. Tele hone#(336)751-8760. `D yo. Y 23L► I Environmental Health Specialist Date: & ?o k7 DCHD 11/06(Revised) A ;C SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NG 27028 (336)751-8760/Fax(336)751-8786 1� � Ap icati Sit$ ��uati rovement Permit ❑ Authorization To Construct(ATC) ❑ Both Typ of Applic-a iofl.. ystem, ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED —711 INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION I Name to be Billed Contact Person Billing Address -w d Home Phone City/State/ZIP trJ . ,,i usiness Phone Name on Pe rmit/ATC if Different than Above . S Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: 0 Site 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 City/State/Zip i Property Address Lot Size Tax P Subdivision Name if applicable) ot# Directions To Site: o 31�A ' 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 o Does the site contain jurisdictional wetlands? ❑Yes No Are there any easements or right-of-ways on the site? ❑Yes No Is the site subject to approval by another public agency? ❑Yes No j Will wastewater other than domestic sewage be generated? ❑Yes o IF RESIDENCE FILL OUT THE BOX BELOW I #People #Bedrooms & #Bathrooms _ Garden Tub/Whirlpool ❑Yes ❑No Basement: es ❑No Basement Plumbing: es ❑No IF NON-RESIDENCE FILL OUT THE B T e of FacilityBusmess Total Square Footage of Building #People #Sinks #Showers #Urinals Estimated r sage(gallons per day) ttach documentation of similar facility water consumption) ERVICE ONLY: #Seats Type system requested; ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Zk,,-, t Water Supply Type: County/City Water ❑New Well OExisting Well 0 Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes r y" 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 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. Site Revisit Charge Property o s or owner's ke epresentative signature Date(s): Client Notification Date: Date � EHS: Sign given ❑Yes ❑No Account# Revised 11/06 Invoice# I i 9 ICATIOA1 F ITE EVALUATIONAMPROVEMENT PERMIT & ATC avie County Environmental Health �y0 P.O.Box 848/210 Hospital Street t �MEp1TPLNF�`jN Mocksville NC 27028 ENv1 p off' _ (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 i` ***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 _ Contact Person Billing Address .'1-2$ Home Phone City/State/ZIP � �_C4 �4 � /�)� �7c j2�_Business Phone cf d -_2 4 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: ite 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 go / t„ City/State/Zip *VL c,,„ce /QC. Z wyCo Property Address C ��1_ City 4`10c kZdl/R_ Lot Size X ee-In 11P Tax PIN# 677q ZkJ'CCI Subdivision Name(if appl ci able) k Section/Lot# Directions To Site: HL-3V (0 4 L C,, ec . 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 ❑N-o Does the site contain jurisdictional wetlands? ❑Yes EKo Are there any easements or right-of-ways on the site? ❑ o Is the site subject to approval by another public agency? e0Y s ❑No Will wastewater other than domestic sewage be generated? ❑Yes BN-o-- IF RESIDEN E FILL OUT THE BOX BELOW #People #Bedrooms q — #Bathrooms Garden Tub/Whirlpool E-Yes ❑No Basement: ❑Yes ❑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: C3C•onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: D-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 3_1q_0 If yes,what type? land. 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 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): 4L– ,,2 Client Notification Date: Date EHS: 1 Sign given ❑Yes ❑No Account# Revised 11/06 Invoice# l I }, UR,� OCT WAJ too styJvl AW SA 7210 x �2 t� Al i ter, . , e WwA r 6149 � +'iia ,�:.", _•�`�-� t� "v -,�+„ � �` _"wa�"�••r-:. G "� '�P y owl £' .y;.i ti -I "T i•.# ' "d a "" '°'a4 N t' 7 'M a r,l ;,� .:'i ,�(,. 2-�T :. �+ r '��� :. s+!�. d e}:�' .X•fi �•.4r���' �� Y{� *`� ;pr wn f�. „ � ,r •#' � 10811 ' �.•. r ��.;..-s r,7 _. . �It�l^�r�t�.r p "k �+ S, 1 i_ w'a('•^^ T'� _ t� T+6 s''. R3 ^r e•,= z xe rcze f� �,Y`•pY�11 t•�e4�.t`F� �l.��� 9''h•?��� �"� /Y " `�� �`.r , ,p ��� Ane ;. I• �"a' a mss, y _ - �.aa 110app .41 VW All save ,�. 's t Jfi g; is j Allyvt. 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DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account M 990004173 Tax PIN/EH M 5748-83-9141.14 Billed To: Land First Development Subdivision Info: Marbrook Lot# 14 Reference Name: Rodney Bailey Location/Address: John Crotts Road-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position ! Slope% -710 I'. HORIZON I DEPTH — D Texture group4L I` Consistence r 7SPI Structure MineralogyS f HORIZON II DEPTH 6 Texture group C 0, a' Consistence " Structure Mineralogy HORIZON III DEPTH 9 Texture group C-t- ; l Gi Consistence ` Structure qn G Mineralogyt h HORIZON IV DEPTH 1- I Texture groupC Consistence I Structure Mineralogyi SOIL WETNESS -- r RESTRICTIVE HORIZON k17, 0 SAPROLITE — CLASSIFICATION LONG-TERM ACCEPTANCE RATE 9•Z S ©-Z SITE CLASSIFICATION: EVALUATION BY: FLONG-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 r 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 Mineralogy 1:1,2:1,Mixed i�tzs 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) f 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#: 5748-83-9141.14 Billed To: Land First Development Subdivision Info: Marbrook Lot#14 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. Permit Type: Z5ew ORepair ❑Expansion Permit Valid for: ❑5 Years,B1lo Expiration Residential Specifications: #Bedrooms 41 #BathroomsZ J #People-!V—BasementO Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):_ Type of Water Supply:,21<unty/City ❑Well OCommunity Well Site Modifications/Permit Conditions: System Type LTAR Initial Repair Site Plan• .0 Z AN R � 4 Environmental Health Specialist Date i.p.11-06