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168 Marbrook Dr Lot 17 DAVIE COUNTY ENVIRONMENTAL HEALTH Pdr • P.O.Box 848/210 Hospital Street - - Mocksville,NC 27028 7/R 7 (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT C i Account M 990004375 Tax PIN/EH M 5748-839141.14 Billed To: DarLyn Homes, Inc. Subdivision Info: Marbrook Lot#17 Reference Name: Location/Address: John Crotts Road-27028 Proposed Facility: Residence Property Size: 265x115x265x ATC Number: 4711 **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. System Type:_S.T.Manufacturer S Tank Date -�� Tank Size i�a Pump Tank Size 1 000 foal System Installed By: �t��' Jti �E.H.Spe 'alist: ate: t] :.9 cry .o u of y,� `i�q 3 - m ri `5 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 1 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account M 990004375 Tax PIN/EH#: 5748-839141.14 Billed To: DarLyn Homes, Inc. Subdivision Info: Marbrook Lot# 17 Reference Name: Location/Address: John Crofts Road-27028 Proposed Facility: Residence Property Size: 265x115x265x ATC Number: 4711 Site Type: ew ❑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 :5> #Bathrooms y #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size Z Type of Water Supply�unty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD)-jot) Tank Size 'AL.Pump Tank GAL. Trench Width,-5tr Max.Trench Depths Rock Depth Linear Ft. Site Modifications/Conditions/Other: L ce'MO@1=: e g% O"t aFF • L I e5 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. As stated In :t5A NCAC 18A.1969(5) accepted Systems may also be used R Bio i /10 I Tt�l� 30; ;2 toy' Lt ,e Environmental Health Specialist Date: (Q J DCHD 11/06(Revised) is P ON ITE EVALUATION/IMPROVEMENT PERMIT & ATC r 2p�1 avie County Environmental Health ��N 1 P.O.Box 848/210 Hospital Street �'. Mocksville,NC27028 A10- (336)751-8760/Fax(3 751-8786 Ea`� O��E00 Applic tion For: a Evaluation/Improvement Permit Authorization To Construct(ATC) ❑ Both Type o ication: ❑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. .l APPLICANT INFORMATION �,, Name to be Billed l,�y n �U.MCOS .� N- , Contact Person CPv. Billing Address t y 3 4/ 6:,,,-Ir�� /�20:�► n Home Phone S City/State/ZIP t.., , s�� - Sc4 --Z 7 Lo--7--Business Phone 7 e) Name on Permit/ATC if Different than Above . Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged / 0 1 NOTE: A survey plat or site plan must accompany this application. Included: 2(Site Plan ❑Plat(to scale) (Permitil valid for 60 months with site plan,no expiration with complete plat.) Owner's Name L ►C,,s-E 7cw Phone Number Owner's Address 2 2 R 1) w y 1✓}n 1 Se 7/► City/State/Zip_ ,-•c. -7 7Oy l Property Address j/s -/-Z o,,9 1--> City Lot Size Tax PIN# S �y�Q R3 / Subdivision Name(if ap icable) Section/Lot# Directions To Site: 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.5No Does the site contain jurisdictional wetlands? ❑Yes O'No Are there any easements or right-of-ways on the site? ❑Yes BNo Is the site subject to approval by another public agency? 0YYes ❑No Will wastewater other than domestic sewage be generated? ❑Yes 6No IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms 7— #Bathrooms Z— Garden Tub/Whirlpool rd'Yes ❑No Basement: ❑Ye ( No Basement Plumbing: ❑Yes tK&o I IF NON-RESIDENCE FILL OUT THE BOX BELOW { Type of Facility/Business Total Square Footage of Building #People i #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested; conventional ❑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 P-<0 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,orif 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 th responsible for the proper identification and labeling of property lines and corners and locating and flagging or sta ' e ho 6facility to ation,proposed well location and the location of any other amenities. :�: Site Revisit Charge PO erty owner's or wner's legal representative signature _ ) _ �- Date(s): 7 Client f Client Notification Date: Date EHS: Sign given ❑Yes ❑No � �A) Account# 37 Revised 11/06 V3 Invoice# _��; hi . a _ fl .'Jam' �,�a, X ` , ' ' 0 69,387 SF �o 1,593 Acres d N t i E;�I�nHc At .4 5 4 1 Pt?E' l y � per_` "�- 12 f 53596 5E ,S 89'13`10' E \ ✓ �' (, r+c, f f 1,230 Acres", 015 . - sem. S j �ry LD )�; S 83'51'55` c e 32,267 o Nuj tat Vu F_ 30 474'SNw I�` �o f �5 r 'SF- (4e alk:Ea ^• 3F312 Sf ii 10, 17 „_ L 2079 29' C 1 M R$RQ0 + DRNE 0 5 PUBLIC_) _� . . S F39'1310'.j t 1412S.1b' i 125.20'^ -=-� 10 00 10' tlttlttynseMent 77 45 "N Co r3 Wm 3 �, L3 0 N o ►. Cu CO 22 �d N._ � d �. 23 N 24 2f N� 25 �o 0 30,118 SF 30000 SF , i, t ti41 TTjo J N 3OIX1.G Qs en 12s.tt0' 15l r 8914100- V 1139 53' ?nt�i ICAT�9O 1 F ITE EVALUATION/IMPROVEMENT PERMIT & ATC $ "� avie County Environmental Health �0 P.O.Box 848/210 Hospital Street SP��FA`�t1 Mocksville,NC 27028 ENV1R��;MEN��, (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 CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed ( _r,�,A !F:.-;A- lC)sz Contact Person Billing Address Hcy X FJ l 6c•,'1` h Home Phone City/State/ZIP—,44&1-.,a 4 :azo a�� 2—2Q9k Business 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 valid for 60 months with site plan,no expiration with complete plat.) Owner's Name „ l - ., Phone Number •- �'C) Owner's Address Sol SC, l„ City/State/Zip d /L,C,. AJC. Z 7yo� PropertyAddress - • o Gn p% C.• a b(�1_ City12-v� Lot Size c5ee-in a Tax PIN#_ 0-7S10kKg1 q%,/7 Subdivision Name(if applicably eSection/Lot# Directions To Site: HL-.1V (04 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 ON-oo Does the site contain jurisdictional wetlands? ❑Yes C31To- Are there any easements or right-of-ways on the site? ❑Yes o Is the site subject to approval by another public agency? ErYes ❑No Will wastewater other than domestic sewage be generated? Dyes B50-- IF RESIDEN E FILL OUT THE BOX BELOW #People #Bedrooms -7 #Bathrooms 7� Garden Tub/Whirlpool (mss ❑No Basement: ❑ es ❑No Basement Plur bing: ❑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: C-onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: D-County/City Water ❑New Well ❑Existing Well ❑ Community Well i Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 8-N f If yes,what type? Ccs nd. This is to certify thaMe 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 I understand that lam 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. -z7,,,/,,7 Site Revisit Charge , Property er' or owne legal representative signature Date(s): 2�}=�� Client Notification Date: Date EHS: j Sign given ❑Yes ❑No Account# 41173 Revised 11/06 Invoice# �vniv vrNv 1 X48 7210 1 wt - F �a ��e _ r ti 9► ,ti,� - ..nr. 61-' . a j..•. � I � l � f� .t $,47 ''�''K\+,�'4 f�Y R'' 'K r .•,_ I : r.r �'�i' _ _ { ..p,. .'.i � 1 A t;Y, ']"`� L a YI,.��� �, ��•��#b a � .y r�, as '�� � '� Y.a* f, ,� _k � y;� t®t .i ofy it nib S �6 x kFr l w ✓ 31A , � .., ..111 r I«.: I r u �;+bt. !'r bi r W Y ! 63 4,' C.rr.t 1 a ;#iR t�r��l } r rs .: vj« 4� 8 ry.r .,'�i :Fi �`iF �t ! �� �R {~I.-. yr"},"'!�.`+�} k t d °.- � r.♦ -- 1:axi1. _ .. •5 �f CO �7.+60 J _ 1•.t a tT I `�, �--- ';+��'�• n* ���. *tom�',;�'� �'1°',� +��� ,��p t'`�*'�,,:�,`�`'$.. y� rr i ;r•:: 40 AT 2 o r IT r 1�,jp LO �.`-. V. z ry 1 �1,2 .n _ v yA�Jy �7 t, � �- ,. W' l r '.. � � _.., w.,al,i�'1riP1V�r� ��.WYII...�r1])�'{1c'i.t.�i!`• I :i JfR 'if c .. _ -4•l I. JOHN CROTTS RD OR 1602 ,pHNC WTTS MAD fOAD 47 L-�9, 07s) s3 l el 0:131 (J.- 00 O 5432 Pa D G n B N ` (a 97 A) 7210 C L- 35 Ei2 A Cp \ 6149 P `Ao —• 7 01� (a 20 A) _ (05,49A) 1 0 0 0181 0 CeB2 < � 1081 h > > (1.81 A �63 co i PcC2 CeB2 0 T364G a D (,5i t�o> SR 0 N ) m 160 W �3 6144 72RA GnC2 1 N GnB2 1 4j ` S4 p RSA) 7617 5a 'Vo m (150) PB3) f� kav I : N.%` \ ti e !% df' .�S � •pry'l On lec 15 �.` ✓i. � f� cid� i ���``. \ a � l t 9'j CJD .o f /- __ 125' � •'� 20� V, - r 20 - On n DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990004173 Tax PIN/EH#: 5748-83-9141.17 Billed To: Land First Development Subdivision Info: Marbrook Lot# 17 Reference Name: Rodney Bailey Location/Address: John Crotts Road-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: "1 11010-7 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 Slope% 7a 7 HORIZON I DEPTH _ O- 1 Texture group CL_ l_. CL_ i Consistence f_S i Structure i MineralogyY i HORIZON H DEPTH 3 62 d i Texture groupC, Consistence r$ T ! Structure < 9 . Mineralogy HORIZON III DEPTH 24 2a Zq- { Texture groupS I Consistence Fr-S i Structure S . Mineralogy { HORIZON IV DEPTH �41M Texture groupSL Consistence i Structure .. MineralogySs h SOIL WETNESS RESTRICTIVE HORIZON — SAPROLITE CLASSIFICATION 1 LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: 1` EVALUATION BY: LONG-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 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 VFl-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 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) 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 M 5748-83-9141.17 Billed To: Land First Development Subdivision Info: Marbrook Lot# 17 Address: 228 NC Hwy 801 NorthLocation/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: New ❑Repair ❑Expansion Permit Valid for: 05 Years 21qo Expiration i Residential Specifications: #Bedrooms #Bathrooms.25#People Basemento-Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):� Type of Water Supply:.�County/City ❑Well ❑Community Well Site Modifications/Permit Conditions: System Type LTAR Initial o•3 Repair 0.27 Site Plan. j , .• � � ,, —0..�--��— — Yi , 1 301.: nPti • —316 .J 1 1 ' UtAlty'Easement 03.39'32' tv 265' 170.58 /L1112 tw r - V . �► e6s• I Environmental Health Specialist Date i.p.11-06