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123 Elberon Ct Lot 3 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 Account #: 990002128 OPERATION PER11fax PIN/EH#: 5748-83-9141.03 Billed To: Phase IV Realty Subdivision Info: Marbrook Lot#3 Reference Name: Location/Address: Elberon Court-27028 Proposed Facility: Residence Property Size: 125x240 ATC Number: 4850 **NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC has been installed in compliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for arm given period of time. 4 ` OC6 System Type: S.T.Manufacturet5lvQ- Tank Date Tank Size _�o Pump Tank Size C, � i System Installed By: t �� E.H.Specialist: 1.'OhJ� Date: / { / � E O D�— C d 0� /G r s 9L I is � o DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-78786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990002128 Tax PIN/EH#: 5748-83-9141.03 Billed;To: Phase IV Realty Subdivision Info: Marbrook Lot#3 Reference Name: Location/Address: Elberon Court-27028 Proposed Facility: Residence Property Size: 125x240 ATC Number: 4850 Site Type: ❑New ❑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 3 #People Basementl'lBasement plumbingC— Non=Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size V / Type of Water Supply: Q'County/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD)-360 Tank SizeAL.Pump Tank/dad GAL. Trench Width 4p(r Max.Trench Depth� ' Rock Depth ) Linear Ft. '�3 C ' Site Modifications/Conditions/Other: As stated in 15A NCAC 18A.19690 --aecpted Sj5tems.--j-ef3�b Contact the Davie County Environmental Health Section for final inspection of this system between 8:30–9:30a.m.on the day of installation. Telephone#(336)751-8760. Cavi �1 r poi 0A ?/,a yr l 1 G 5 s \ ri.aX CFP 1 �-Ip wrap 5 y iy, •n LAJ', l I h J W/1410 Environmental Health Specialist Date: DCHD 11106(Revised) -� EC E9WE APPLICATION FOR SITE EVALUATION/I I & ATC Davie County Environ Ile , , $ 2�$ Ie�' P.O.Box 848/210 Hosp 1 ree Mocksville,NC 2V7028 t11� (336)751-8760/Fax(33 )751-87WARONMENTAL HEALTH DAVIE COUNTY Application For:4te Evaluation/Improvement Permit 'Authorization To Construct(ATC) ❑ Both Type of Application: 1ew 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 C-, lit //—Contact Person �'2 u2c 5 Billing Address „F. Home Phone — cf City/State/ZIP ' siness 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 ❑Plat(to scale) . (Permit is vali r 60 mont} th site pla exp' tion}i✓i comple e p at.) Owner's Name f Q / Phone Number Owner's Address City/State/Zip Property Address /�-v,^/ City aby C Lot Size r,� �j Tax P/N# — — R tt Z13 Subdivision Name(tf applicable) 01b Sect' n/L t# Dire ions T Site: _ �i C /",q If thea er to any of the following questions is"yes",supporting documentation st be attached. Are there any existing wastewater systems on the site? ❑Yes P&O Does the sitecontain jurisdictional wetlands? ❑YesAlo Are there any easements or right-of-ways on the site? ❑Yes o Is the site subject to approval by another public agency? ❑Yeslo Will wastewater other than domestic sewage be generated? ❑Yes o IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms — #Bathrooms _ Garden Tub/Whirlpool es ❑No Basement: es ❑No Basement P umbing: es ❑No . IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBdsiness 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:AConventional ❑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 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 i of catio nd labeling of property lines and corners and locating and flagging o taking the house/facili location,propose e 1 at' nd the location of any other amenities. � e w Property wner's r o er's representati a signature Site Revisit Charge � Date(s): Z4 ( b ` q � Client Notification Date: Date EHS: . Sign given ❑Yes ❑No Account# Revised 11/06 Invoice# ' ICAT ( T F ITE EVALUATION/IMPROVEMENT PERMIT & ATC a � avie County Environmental Health P.O.Box 848/210 Hospital Street �MEp1�P1 NFp`�t1 Mocksville,NC 27028 (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_( �� -:r;� l�Q,/e �, p,.,,�-}' Contact Person Billing Address Hw X h Home Phone City/State/ZIP S.,4 �4 4. A JY' 7y0 Business Phone !26 - 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: Btlite Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name �-.� ., Phone Number O L(.-S&)3 Owner's Address Rol S� L, City/State/Zip 11QLW ,.rLe /AJC. Z wn(o PropertyAddress - -.1,Gg kN C.�a ;G��_ City VMvc- Lot Size c22,inim Tax PIN# -57V 0��,'�✓�/.Q3 Subdivision Name(if applicable) W&.[0,-,-o k Section/Lot# 3 Directions To Site: H L.3 V (p t.{ 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 ❑3q-0 Does the site contain jurisdictional wetlands? ❑Yes IN 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 IF RESIDEN E FILL OUT THE BOX BELOW e,dwil D m/QOW u #People #Bedrooms / #Bathrooms 7i Garden Tub/Whirlpool Dyes ON Basement: ❑ es ❑No Basement PI—umbing: ❑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: =76nventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: D3 C unty/City Water ❑New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes aliq If yes,what type? t c��s Cep r III H724f Vs Ca nd This is to certify thale 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 owne0slegal representative signature Date(s): 4Z- ;2 Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# 4/73 Revised 11/06 Invoice# i i 1 n. J ,y Y. •-.S i V1 its 4 \ J .r „ ./ rp 27, i T'LIIV% �'bIRECT_DN= iIISTANCE� ! j L-1 S 89'31'19' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990004173 Tax PIN/EH M 5748-83-9141.03 Billed To: Land First Development Subdivision Info: Marbrook Lot#03 Reference Name: Location/Address: John Crotts Road-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: 11D tJ7 Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit ✓ Cut FACTORS 1 2 3 4 5 6 7 Landscape position L t_ Sloe % 1 tis Zo HORIZON I DEPTH C>—J C2"Cp C9 ' Texture group SCl_ GL- L Consistence Structure Mineralogy5 HORIZON R DEPTH Texture group Consistence rGV Structure Mineralogy HORIZON III DEPTH 30 - Texture group Consistence ; �j -i , Structure t MineralogySu HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS aZl L RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE Z� SITE CLASSIFICATION: P.� EVALUATION BY: LONG-TERM ACCEPTANCE RATE: 0- ✓ OTHER(S)PRESENT- REMARKS: RESENT:REMARKS L GEND 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 I SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay . CONSISTENCE MQLq J VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm J 3yri 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) LTAR-Long-term acceptance rate-gal/day/ft2 DCHD 05/05(Revised) • , f 66z JOHN CR OTTS RD 52o, 4763'Zi %AD BRI602 PHNCfOTTS MAD ,- �a�y �0 0 _7648 5 e 447 m 00 L514'43 PaDGnB (a97A) 7110 16 EPA cR 6149 o'�.� % � 9 fiFl (apq) (03494) 0181 9141 �o CeB2V-76 h� a (1.81A �63 0) CC) PcC2 B2 M64 Ce B2 ® (1S ER N 1 v 160 W (16.9 a4) 6144 2z2 739A GnC2 1 r GnB2 62 (2 67 7617 su x1059 9546 •- 5id co 310 r 31c(_ _ JOHN ;�R��S R 7. I r„�n a .a-: i tom_ ��'�+� �a., � x?•7� °t:, ,,�u, h E; � � 6631 ., .gyp �, l�:gl •�"h:P! t°��i �v-.a. :: ,• -.� -' _ co •fir z � - hn� E for _ t ' nT210 �' M1�^A� `Gw� na � xr"�`tu` � '�3 J �f(RS4Q4�," t .g, �`.:qui �..,i � r -� i�ar3 J 3 • � 9 ..9` .� .. a'` \;: =1®i ,a s�,',, �:�* i�'` $141, a`•�+.y g�pl"at '�`p�§' 1 �. r rr t,.I�f .. +� ,;� i, ,r " ,�,_ - .. ,,�k + ret N I. �' � '.�• Qy .+ P ! (I .�' �/ f � e .r��lr- _ J �•r �" ?,�j � I ki � �r h r,p � � If,. � ..r ��- l l r a y '„ .�. 'Y.^I"a:f'a al,�+ S '•''f „�� .. ::z; "'e ,` :. :� . .�co - w Y'lM'F �"e � �.:tf F 7i t t � .S S'yf'�T i". P• }Y..A � �P �.� �� R� r r '�' i >«�-.�,�f�� '� } A�,.—f6 ,y�� 1 j h•s r~� 2St>f7 .� '�:w � ,_,,/,� J}a n �€�,,,t e - irk 4.f' •�d � -I .,�q •a� �r r y. f «+� ri��. �P .��`,.y, '•!��.A''� �; �'.N��'�Alr {�' '-gn�f�' �� _ �r �v� ,�.: _- - 1. 1 _ 1�5 : l;f/ i`. a lJy:X �s*C� r1j� '., 'y l 1 ..� a` + ,. '.,/ y ? ',•a 1 sxl _._ rAM. Al r t`°....' •p^ P"'r '`: ,1i1 f ,.'.+r -fir +F+' r rr,. �°``fir ''l •f'Y e7Fr :'#7 .�".p l�•T-,' ^i-..R"� i �M t tt �' ��i far �"� f �"17'?'- R`i � f•.. 4' t-n P' c^* ':` A '(i 4yr•'K'-R :sr/,r1 `a typ JVrA ".Tk,,,•` t 1 4 t`. �.F ��,�:'{` t 'a .� �-� � �Ya` ',` n a � •II L�(e',y+ �a' _ -; a fy .' N w Yi. 1oZrjl i i �- � 0 � �G 5 ' a r { r x Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account M 990004173 Tax PIN/EH#: 5748-83-9141.03 Billed To: Land First Development Subdivision Info: Marbrook Lot#03 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: R<ew ❑Repair ❑Expansion Permit Valid for: 0 Years ;Rlo Expiration Residential Specifications: #Bedrooms #Bathrooms Z #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): Type of Water Supply:,Er(!5ounty/City ❑Well ❑Community Well Site Modifications/Permit Conditions: System Type LTAR Initial Repair Site Plan 1 l SA Lr ell t . i Environmental Health Specia st Date 4 7 _ i.p.11-06