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160 Marbrook Dr Lot 16 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 M 990004173 Tax PIN/EH#: 5748-83-9141.16 Billed To: Land First Development , Subdivision Info: Marbrook Lot# 16 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 i **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: ew ❑Repair ❑Expansion Penn it Valid for: 05Years o Expiration I Residential Specifications: #Bedrooms--4—#Bathrooms2� #People j Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): Type of Water Supplyunty/City ❑Well ❑Community Well Site Modifications/Permit Conditions: -Y U9Q MAV AV E)C auoo 1 gc System Type LTAR Initial ,Z Re air Site Plan d i �a Ivr t Environmental Health Specialist Date ?i O i.p.l l-06 ICAT�jQ1 F ITE EVALUATION/IMPROVEMENT PERMIT & ATC avie County Environmental Health P.O.Box 848/210 Hospital Street �MENjP�tyA`�N Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 I 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 c.." E-:f;A– Contact Person r -�ne Billing Address _��$ f�r� X �J / 6o'1-h Home Phone o City/State/ZIPS, /f/� �7L,QBusiness Phone d - Name on Permit/ATC if Different than Above r Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: Ergite Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) C Owner's Name E: ,Z v c �--p �, Phone Number �t�Jt .-5st)3 I Owner's Address o/ 5e,, t^ City/State/Zip z� t✓c,AL2 /trJ,C. w o(, Property Address_'_J�G,t..\ /( ,, , J_ City, 1;1vC-AZa/R_ Lot Size c5ee-M a Tax PIN# -5 7V ZkTq1 q/,b Subdivision Name(if applicable) k Section/Lot# Directions To Site: HL-5V (a t{ LIF I If the answer to any of the following questions is"yes",supporting documentation must be attached. j Are there any existing wastewater systems on the site? ❑Yes ❑3-o i Does the site contain jurisdictional wetlands? ❑Yes ❑'ice Are there any easements or right-of-ways on the site? ❑Yes 0 Is the site subject to approval by another public agency? e0I' s ❑No Will wastewater other than domestic sewage be generated? ❑Yes 8156 IF RESIDEN E FILL OUT THE BOX BELOW #People #Bedrooms #Bathrooms Z- Garden Tub/Whirlpool [ 'hes ❑No Basement: ❑ es ONO 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: =5nventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: a-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_ If yes,what type? Was 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,0 legal representative signature Date(s): 41-1– Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# 173 Revised 11/06 Invoice# 'll. s.oi 4763 . d ` l = ;lOHN CRO T'TS RD- 5 7648 00 &+31 ., Mr t'+� { 4 _ •4" y+ s'9i a^x3ay s'`,Ay....Si,.JI ;,y,,. r S t' a.., " F• ,1 .} �:. a �.k � '� '.4r iF`$F Jj��* Yl'�L n�'. •�4ik '.;fE a�¢, � � �, - S �, ' �.�" � ,'�� s�x +•� � '4�a��,'�, �"' � � ` `' '1;- . is 7,110 E'N tib• Y .f� rt.} A . �� f''a ' :� iii✓.'.A y � .. a• %" tT S fir , �' ��rr a ^,�' �' J yi ,�{ Q 76A �� .. ��."+E .,"` �''F��r��k�`F�yT �� ' tr� V.. '_ � �� »r �,'#� -:��i ?�� _�Llf �. J ��,/Sr��k• 1081 a. 81 A co +a �', g�Y., f _'r'f yY"a t..4 � J 4' n�. •�•l:. �-j � �"-� \ ' - - iTi-Y YPYRi �i. s_ 917 4lu"�: Yf"' { 9 � J;` ! `�bS ,� ��•:. � Y y� di •, `y.;�rc7 io Y Yt Y?`s A Z Wi 11� P f y } gt� ',3: f "fFJ °.} .: ` �V: ,! •._; i,#ir J t4!, c,.:{ _ 1"� .,. J f,yi `,..sY .Yi"._...a_. _ M...+L_•__.... "� 4'r __.*,,,R.. r 1 '. `� ✓ F 4 Fit P ' 1, « PAY'. iI - 614¢ SAL iz 6/,Y IIY ._ ..y`tdD a� .f`�' fit• .3` � I ier � — I JOHN CROTTS RD t 526 4763 - aa (6621 �� - 7648 5 OR 1602 PH14CFCTIS ROAD 40FOAD ,g Z7 °9f__ ° 6) ° Q"jgl (,76)Lpj,'432) g \ X31 (1 1*17 PaD GnB (397A)7110 9.662A \ 6149 % o ( 20A) 9141 0181 �6 CeB2 -� 1081 a �J .� (1.81 A 63 00 00 s� PcC2 CeB2 GaD (,5 sq co 160 W Q 6144 2 222gA GnC2Lo l r GnB2 ` 94 - \ �z (Z 67 A) 7617 60 2tU 9546 old4 50) r2D31 m � 4 Q n � ii ,was 19k r � _ 1 s °00Lj CL N•i M r' IAt 1\ r. r zr L till `r a 5 i i 125, - 71 zr � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account M 990004173 Tax PIN/EH M 5748-83-9141.16 Billed To: Land First Development Subdivision Info: Marbrook Lot# 16 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 i Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position (— L Slope% HORIZON I DEPTH p -1 1 Texturegroup Ct_ G_ Consistence W S Structure C(2- Mineralogy HORIZON 11 DEPTH 1 Texture group G Consistence r F.-csvfsp Structure ,5 Mineralogy HORIZON III DEPTH l?6 - 1le-4V SZ Texture groupC11,0 L Consistence Structure Mineralogyt L N HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS — r RESTRICTIVE HORIZON — - - SAPROLITE '- CLASSIFICATION PS LONG-TERM ACCEPTANCE RATE O.27> D. O • t SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: D.277 OTHER(S)PRESENT: REMARKS: AM_ iV� X�� (►� CYSg W G ± 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 CONSISTEN . . Ml2ist VFR-Very friable FR-Friable ' FI-Firm VFI-Very firm EFI-Extremely fine 33'_et NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky t 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 LYt2tg.T _. . 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/fU DCHD 05105(Revised)