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135 Elberon Ct Lot 12 i DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 r (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT Account M 990002128 Tax PIN/EH M 5748-83-9141.12 Billed To: Phase IV Realty Subdivision Info: Marbrook Lot# 12 Reference Name: Location/Address: .John Crotts Road-27028 Proposed Facility: Residence Property Size: see map 135 QheE(w416f• ATC Number: 4699 **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 any given period of time. A System Type: "t S.T.Manufacturer Tank Date Ta e_[= Pump Tank Size System Installed By: I� E.H.Specia ate: l� 4�7 iyS 1ID t 1 Als SZ f o rea- DCHD 11/06(Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account M 990002128 . Tax PIN/EH#: 5748-83-9141.12 Billed To: Phase IV Realty Subdivision Info: Marbrook Lot# 12 Reference Name: Location/Address: 'John Crotts Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 4699 Site Type:,Wloew ❑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 #Bathrooms 2,.5##People Basement❑ Basement plumbin;P" Non-;Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size Type of Water Supply�ounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD) ank SizeGAL.Pump Tank GAL. Trench Width of Max.Trench Depth ✓l� a Rock Depth IL Linear Ft.1"7�0 Site Modifications/Conditions/Other: rJ8�L V—L� 1c; Contact the Davie County nvironmental Health Section for final inspection of this system between 8:30—9:30a.m.on the day of installation. Telephone# 336 751-8760. p¢.4 L-1-.1C X734 12 41 lip 1'S L'J _ FQCR L-10 As stated in 15A NCAC 18A.1969(5) accepted Systems may also be used Environmental Health Specialis Date: qql DCHD 11/06(Revised) I Ci T R SITE EVALUATIONAMPROVEMENT PERMIT & ATC ��----- Davie County Environmental Health P.O.Box 848/210 Hospital Street MAY 3 207 Mocksville,NC 27028 i (336)751-8760/Fax(336)751-8786 App hcatidfi oz:. i e valuation/ provement Permit ❑ Authorization To Construct(ATC) ❑ Both . C T e of Appli`cittion. ew ystem flRepair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED a INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION } i Name to be Billed Ci>P Contact Person Billing Address Home Phone — i City/State/ZIP (O Business Phone ctf 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 valid for 60 months with site plan,no expiration with complete plat.) Owner's Name Phone Number I Owner's Address City/State Zip i Property Address_ Gt/� !'.�c1- City. 1710C Lot Size Tax PIN Subdivision Name(if applicable) Section/Lot# Directions To Site: " II 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 ❑No 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 Will wastewater other than domestic sewage be generated? ❑Yes ❑No IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms #Bathrooms Garden Tub/Whirlpool�'es ON Basement: es ON Basement Plumbing: es ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness 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-Aounty/City Water ❑New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes J�No If yes,what type? l \ 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 tha I am r spons' for the proper identification and labeling of property lines and corners and locating and flagging or stakin&.the use/f lity oc tion,proposed well location and the location of any other amenities. Site Revisit Charge Pr erty owner' or owner's legal representative signature Date(s)- Client Notification Date: Date 4 EHS: Sign given ❑Yes ❑No Account# P?lp%o Revised 11/06 Invoice# 4 Jun 04 07 07:03a Phase Iv R€altu (336) 746-1332 P.2 H - 5- 1 n ! f a �r �-�----� l'ati51 i �LICAT QF i ITE EVALUATION/IMPROVEMENT PERMIT & ATC avie County Environmental Health P.O.Box 848/210 Hospital Street �MENtP��FA`ZH Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 Applic n or: Site Evaluation/Improvement Permit ❑Authorization To Construct(ATe) ❑ Both u 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 V INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be BilledL r 1-:.-;�- 17Q,�Q<<, p,,,.,--� Contact Person Billing AddressHome Phone City/State/ZIP Z-7L,Q _Business Phone 6 - 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 sse)3 Owner's Address o/ S�, t^ City/State/Zip f&Juc,,,.,« TQC. 2 7vy(,, PropertyAddress o G,r•� C.�o KJ_ City Lot Size 622- Tax PIN# o77V�Ugq/q 17- Subdivision ZSubdivision Name(if applicable) Section/Lot# Z Directions To Site: Hoy (04 L 'i-- T�1^►� Cfv �tl. S tit1 ;v:5 -. c� L e — 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 DN-o Does the site contain jurisdictional wetlands? ❑Yes ON-o Are there any easements or right-of-ways on the site? DY es o Is the site subject to approval by another public agency? es ❑No Will wastewater other than domestic sewage be generated? ❑Yes B15o IF RESIDEN E FILL OUT THE BOX BELOW0 -4 Ue,e,vauaed 1.TP 6 ,b�droon� #People #Bedrooms 4V #Bathrooms Garden Tub/Whirlpool (mss ❑No Basement: ❑Yes ❑No Basement Pl—umbin—g: ❑Yes ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityMusiness 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: ❑'C•onventional ❑Accepted ❑Innovative ❑Alternative ❑Other I Water Supply Type: D-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 alig If yes,what type? 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. 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I 11 ... 125, / 2 .23 , 29-4 DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account M 990004173 Tax PIN/EH M 5748-83-9141.12 M Billed To: Land First Development Subdivision Info: Marbrook Lot# 12 Reference Name: Rodney Bailey Location/Address: John Crotts Road-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: o t Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 67 Landscape position L_ t Slope% k HORIZON I DEPTH F> D^") O --7 k Texture group C_L_ Cl_ i Consistence IsS t Structure i Mineralogy HORIZON 11 DEPTH 7-2S -7 -2--7 , l: Texture group fi_59 ' C Consistence t5 V 1,r Structure 5 5 l Mineralogy 5EW S" HORIZON III DEPTH 2S g Z17 _q8 I Texture group S,(- G'} V Consistence ;$ 1 Structure c i Mineralogyd HORIZON IV DEPTH C Texture groupi Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE - CLASSIFICATION PSI LONG-TERM ACCEPTANCE RATE .2 -2 SITE CLASSIFICATION: EVALUATION BY: GJ�t�. LONG-TERM ACCEPTANCE RATE: Q 2� OTHER(S)PRESENT: REMARKS: I" 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 4 Texture S -Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt 3 SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CnNCISTENCE - 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 Notes Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface I Saprolite-S(suitable),U(unsuitable) Soil wetness -Inches from land surface to free water or inches from land surface to soil colors with chrome 2 or less Classification-S(suitable),PS(provisionally suitable),U(unsuitable) LTAR-Long-term acceptance rate-gal/day/ft2 DCHD 05105(Revised) R , N • Davie County Environmental Health f P.O.Box 848/210 Hospital Street } Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 990004173 Tax PIN/EH#: 5748-83-9141.12 Billed To: Land First Development Subdivision Info: Marbrook Lot#12 Address: 228 NC Hwy 801 North Location/Address: John Crofts 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: ;Kew ❑Repair ❑Expansion Permit Valid for: ❑5 Years�lo Expiration Residential Specifications: #Bedrooms 3 #Bathrooms 2,�#People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):� ,Yo Type of Water Supply: County/City ❑Well ❑Community Well Site Modifications/Permit Conditions: System Type LTAR Initial - !t. b L D.Z Repair c� Site Planui! .L IN1T1r-A. 1' Environmental Health Specialist Date i.p.l l-06