129 Marbrook Dr Lot 28 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#: 5748-83-9141.28
Billed To: Land First Development Subdivision Info: Marbrook Lot#28
Address: 228 NC Hwy 801 North Location/Address: John Crotts Road-27028
City: Advance
Property Size: see map
Feference 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: /Kew ❑Repair ❑Expansion Permit Valid for: 05 Years 21<o Expiration
r
Residential Specifications: #Bedrooms �3 #Bathrooms 7• #People Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): Type of Water Supply: Zounty/City ❑Well ❑Community Well
Site Modifications/Permit Conditions: O 6L'Co'*> F200"
nl 4l
System Type LTAR
Initial
Repair d.Z
Site Plan t t � �- n�� '' " - LWS3 3J�t;JIV21tt
41� Z
�ln&L ....
•A6 38 SS- ��.
X trs
Cl
loo
n
ti
so
Environmental Health Special tDate p
i.p.1 l-06
ICAT OAT F ITE EVALUATION/IMPROVEMENT PERMIT & ATC
avie County Environmental Health
P.O.Box 848/210 Hospital Street
O�ME�jP` `ZN Mocksville,NC 27028
(336)751-8760/Fax(336)751-8786
Applic n 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 n i
Name to be Billed_L �� E-:r;'t- I�Q pie o D '� Contact Person___K b"-
Billing Address _A,�$ ill-, y FJ l 6c>V1-h Home Phone
City/State/ZIP 14&� 4 4. AJC 2-7vQABusiness Phone --3 O
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 v-V.0-C "Z I Phone Number �� .-iso
��/ � 'I
Owner's Address o I S� L, City/State/Zip �7rl�.c...L¢_ A-JC. Z 2-20(,
PropertyAddress_.I�G.v� C f a 6(�J_ cityl l�1 v� AZ- i'l/Q
Lot Size c522,i12 Tax PIN# -57! 9tZ-1 /,7
Subdivision Name(if applicable) r k Section/Lot#
Directions To Site:_HL.5 V (p(4
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? Dyes ONO-
Does the site contain jurisdictional wetlands? Dyes Gly
Are there any easements or right-of-ways on the site? 0y5o
Is the site subject to approval by another public agency? es ❑No
Will wastewater other than domestic sewage be generated? Dyes Bl -o -
IF RESIDEN E FILL OUT THE BOX BELOW .S't�e�✓Q>'Gf ion �>� 3 /ODry1S
#People #Bedrooms #Bathrooms 7� Garden Tub/Whirlpool B Yes ❑No
Basement. OV
es ONO
Basement Plumbing: ❑Yes ❑No A
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: onventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: 0-C"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 Q'No
If yes,what type?
WL+� V'-E'.i�� G%��l/1/,�"'L%'LIS 1�.�wlZ✓t`
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 '
Propertyer' or owne legal representative signature
Date(s):
411- ;2,}=�� Client Notification Date:
Date EHS:
Sign given Dyes ❑No L/j Account# /7
Revised 11(06 �ll Invoice#
Ili' \ _
1 1 ��
t`
�tun
a
:N v3,
\131' N
14
1
25 X7771- , _-- �ac.
27
f -
LIN_� Il1REC rlon L �I:.i AAA
' L
L S 87'C"081 E__ ._ 9
L-3 S 76'4,'"37' E'
8.
L-4 S 62'5:'05' _.__. 7f
�. _
r-
_ _ L-•c; S 41'4F.:'28' L 71
20.41'36'_. ti
L '3 S 13'4r'L3` 131
7' L-9 S05.3°-y24'._.`-__ - -7E
L-loS 12-w4'33' E - -'
L-I1 S 32'5F p6;— - n
NOW
7 R �
'17
tf' ��: a" •�+ .r+ did s
n.97A
' ri
r} r3 '�'r, ! $°t �, '�� '� k, ,`^ x_ t l• 71104 'J2
� F Y
1091
��' si' +'.�._ '... �L "' }*`-•`,r r ' r e �+ Yr s" f'� Pad +:.` k�u ;T3
¢ tjr
' - ,�.BOJ. .. ,; r r.x•�''}; *.`-d.cj�im.c. r{1`•��.9 I � "• �, ��
P r
,y t
1' �eY
r ¢� "i A�`. y+�7 �+.y7`� �"' a�3 �L�fIT {� •>^-x+ p r'r ; , �,.A`°.: t::K;: ,is�
f```'"'•'� ppJr. ��`..'r� 'F ��, � ��'� ����fir. +r''r s f.�f{ �J:.
3}..
C
r' or
41
+g4 it,
S
zr
.� .w•n�i ^t,� ,�aq�,, r, x.,.9� t�;, !� a _. .\ _, � ,. ,�+
Ar'J
^?..
s y i
y
Y ry
"AZWk
} c it ,• ' �
r
I
I
S R;7 (�R, 47e,—
JOHN CROTT 2„i
e
was y
521602 PHNC';DTTs FU`D 60
0331 t�
.re) (176) a2 \
(11
(3.03 00
32 � � � - � °° o s 7A
GnB
N \
(a 97A)
N 7210 y
s.6692A o0
\ 6149 %
m 20A) 94 41) lis
081 _ 1 a
g
CeB2 ' X81
a G3�
(1.81A
�63
� 00
PcC2 CeB2 �- M64
GaD (,5
N
160.
CO
(16,984) 1
6144
2 2[-!WA
GnC2 l z
GnB2
54
42
(267A)
7617
J X2,0
�ip69 ` n 95�
p
19 5
I/SOi !2831
i
DAVIE COUNTY HEALTH DEPARTMENT
` Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFOR I
Account M 990004173 Tax PIN/EH#: 5748-83-9141.28
Billed To: Land First Development Subdivision Info: Marbrook Lot#28
Reference Name: Rodney Bailey Location/Address: John Crotts Road-27028
Proposed Facility: Residence Property Size: see map Date Evaluated: 10 b1
Water Supply: On-Site Well Communis Public
Y
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7j'
Landscape position L L L G
Slope% X20 7.0 f
HORIZON I DEPTH O— O.3 4
Texture group OAi
Consistence I
Structure 1.
Mineralogyt
HORIZON II DEPTH
Texture groupG N
Consistence V6
Structure < C
MineralogyI
HORIZON III DEPTH i
Texture group I �Q VI
Consistence 1 ri I
Structure C
Mineralogy t
HORIZON IV DEPTH i
Texture groupl I
Consistence I i
Structure N I
Mineralogyp
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION 5 p
LONG-TERM ACCEPTANCE RATE 0.5& a• t I
Q\\ p
SITE CLASSIFICATION: T J �"S -� EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: a / OTHER(S)PRESENT:
REMARKS:
LEGEND
T, n s ane 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
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 i DCHD 05105(Revised)