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169 Marbrook Dr Lot 23 - DAVIE COUNTY ENVIRONMENTAL HEALTH � I P.O.Box 848/210 Hospital Street Ili Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 �, -2 LI/ (/ OPERATION PERMIT Account #: 989900050 Tax PIN/EH #: 5748-83-9141 Billed To: Wayne James Construction Subdivision Info: Marbrook Lot#23 Reference Name: Location/Address: John Crotts Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 4675 **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. ff� System Type: S.T.Manufacturer5RO Tank Date� }'` Tank Size 600 Pump Tank Size -- System Installed By: 4&fei k E.H.Specialist: L6Y15Date: v +� v Y i 4 � � �f- I D/i bt �y DCHD 11/06(Revised) • DAVIE COUNTY ENVIRONMENTAL HEALTH I v ' P.O.Box 848/210 Hospital Street I Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account M 989900050 Tax PIN/EH M 5748-83-9141 Billed To: Wayne James Construction Subdivision Info: Marbrook Lot#23 Reference Name: Location/Address: John Crotts Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 4675 Site TypeXw ❑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 Basement❑ Basement plumbinga� Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size d Type of Water Supply o ! bounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD) ✓ 1'Tank Size I COD GAL.Pump Tank GAL. Trench Width Max.Trench Depth_ ,� `nRock Depth 12- Linear Ft.`TSV Site Modifications/Conditions/Other: l 1vQ� C� �,1 V V 1� c� vpr— 646-*400 Lt i Cqntact the Davie County Environmental Health Section for final inspection of this system between J�fNL 8:30-9:30a.m.on the day of installation. Telephone# 33 751-8760. -iv��r�► 10' 1. ST . As stated In 15A NCAC 18A.1969(5) accepted Systems may also be used Environmental Health Speciali Date: DCHD 11/06(Revised) R SITE EVALUATION/IMPROVEMENT PERMIT & ATC =� Davie County Environmental Health t < P.O.Box 848/210 Hospital Street if 1 h Mocksville,NC'27028 (336)751-8760/Fax(336)751-8786 pph tiFat;.1 `; '' �aluatio °provement Permit ❑ Authorization To Construct(ATC) ❑ Both ype of A "' m ❑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 gat f 1 Contact Person Gt/ ,�.�� �nr%5 Billing Address r0,.,9v,1 Home Phone 25y- - 2/16 City/State/ZIP J1/C 7e?-65 Business Phone 7/:28 f 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 fo 60 months with site plan,no a piration with complete plat.) ^ Owner's Name 1 -4 F"-ZS4- bew-lo o mp-IJ Phone mber 7Qq-3863 Owner's Address e ly W y f-0 7 S- City/State/Zi f(wo-e, 17 Property Address S City t' -( Lot Size ) Tax PIN# 3-9 IVI. Subdivision Name(if applicable) OL Sect16n/Lot# Directions To Site: (p &.TLkd4( 476-hn 60 00 N • i If the answer to any of the following questions is"yes",supporting documentationmust be attached. Are there any existing wastewater systems on the site? ❑Yes ❑No Does the site contain jurisdictional wetlands? ❑Yes 4�TRo Are there any easements or right-of-ways on the site? ❑Yes ffRo Is the site subject to approval by another public agency? ❑Yes- No Will wastewater other than domestic sewage be generated? ❑Yes OTTo IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms 3 #Bathrooms .3 Garden Tub/Whirlpool Wes ONO' Basement: ❑Yes EtNo Basement Plumbing: C9'Yes,❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW I 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; CKonventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type:el ounty/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 L-wo 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 perniit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,of 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 Prope wner' or owner's legal representative signature Date(s): ! er7 Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# I��0650 Revised 11/06 Invoice# ' I �I • DAVIE COUNTY ENVIRONMENTAL HEALTH I v ' P.O.Box 848/210 Hospital Street I Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account M 989900050 Tax PIN/EH M 5748-83-9141 Billed To: Wayne James Construction Subdivision Info: Marbrook Lot#23 Reference Name: Location/Address: John Crotts Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 4675 Site TypeXw ❑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 Basement❑ Basement plumbinga� Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size d Type of Water Supply o ! bounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD) ✓ 1'Tank Size I COD GAL.Pump Tank GAL. Trench Width Max.Trench Depth_ ,� `nRock Depth 12- Linear Ft.`TSV Site Modifications/Conditions/Other: l 1vQ� C� �,1 V V 1� c� vpr— 646-*400 Lt i Cqntact the Davie County Environmental Health Section for final inspection of this system between J�fNL 8:30-9:30a.m.on the day of installation. Telephone# 33 751-8760. -iv��r�► 10' 1. ST . 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Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION ` Name to be Billed � :-; 47 � _� Contact Person Billing Address Hwy Fd l SomIt Home Phone City/State/ZIP Z—aA2jb 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 PhoneNumber--D 7 -3se)3 Owner's Address go// .Se, t^ City/State/Zip 4JL c,,r« Z%-JC. Z Property Address .1 G.v� C.• a e,]- City Lot Size c'$2-in f��_Tax PIN# ,�'�I Subdivision Name if a licable ,� I' (' pp ) ( ��k Section/Lot# 23 Directions To Site: HL-3V (o c{ 1-7 �- T��^►� C r U �tl 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-o Does the site contain jurisdictional wetlands? ❑Yes ONo- Are there any easements or right-of-ways on the site? ❑YesRN_o Is the site subject to approval by another public agency? e0 Y s 0N Will wastewater other than domestic sewage be generated? OYes -leGi ZP 3Bed1donts IF RESIDEN E FILL OUT THE BOX BELOW #People #Bedrooms � #Bathrooms Garden Tub/Whirlpool (mss. ❑No _ Basement. ❑ es ❑No Basement Plumbingmbin�g: ❑Yes QNo �f 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: D-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? Wac Gent t-_p1n,24 vVs- Ccs This is to certify thate 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 legal representative signature . Date(s): Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# ?� Revised 11/06 Invoice# I � vriv t.: v i ► .� , f P141 Ill PMID - . 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J 1 i w ?�S _ //.�:)/ll<.;';•' SRI•;":JN .,7ad i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990004173 Tax PIN/EH#: 5748-83-9141.23 Billed To: Land First Development Subdivision Info: Marbrook Lot#23 Reference Name: Rodney Bailey Location/Address: John Crotts Road-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: 1 ff C5 7 i Water Supply: On-Site Well Community Public / Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 71 Landscape position L € Slope% t HORIZON I DEPTH (9 -10 C>- p G Texture groupOIL alf Consistence Structure Mineralogy HORIZON R DEPTH 10 23 Texture group C F Consistence I Structure PvSkI MineralogyI HORIZON III DEPTH Z� ,.,-Texture group C-k<Sto Consistence I Structure 3 L f Mineralogy p mp I HORIZON IV DEPTH I Texture,grou9cc XI Consistence I Structure Mineralogy1 ' SOIL WETNESS — I RESTRICTIVE HORIZON SAPROLITE — I CLASSIFICATION I LONG-TERM ACCEPTANCE RATE 12.217Y II" SITE CLASSIFICATION: PS EVALUATION BY: 1'i- 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 CONSTSTENCE MQ1St VFR-Very friable FR-Friable FI Firm VFI-Very firm EFI-Extremely firm I NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic Structure I SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic 4 Mineralogy 1:1,2:1,Mixed motes Horizon depth-In inches Depth of fill-In inches r 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/&y/ft2 DCHD 05/05(Revised) d ! - Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 l IMPROVEMENT PERMIT Account #: 990004173 Tax PIN/EH#: 5748-83-9141.23 Billed To: Land First Development Subdivision Info: Marbrook Lot#23 Address: 228 NC.Hwy 801 North Location/Address: John Crofts Road-27028 City: Advance Property Size: see map Reference Name: Rodney Bailey iProposed 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: ITN-ew ❑Repair ❑Expansion Permit Valid for: 05 Years o Expiration Residential Specifications: #Bedrooms .5 #Bathrooms,?-!5#People—�' Basement❑ Basement plumbing❑ d, Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):� Type of Water Supply,;,�ounty/City ❑Well ❑Community Well i Site Modifications/Permit Conditions: System Type LTAR Initial e cg WYGA)— O. Repair Site Plan - � � fey l 1 174 >;t'3 t Environmental Health Specialis Date f I, i.p.11-06 {I