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176 Marbrook Dr Lot 18 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 #: 990002128 Tax PIN/EH M 5748-83-9141.18 Billed To: .Phase IV Realty Subdivision Info: Marbrook Lot# 18 Reference Name: Location/Address: John Crotts Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 4698 Site Type:/I 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 3 #Bathrooms47—'57#People Basement❑ Basement plumbin9r", Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size I' � Type of Water Supply:�unty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD),;LQ_,JI'ank SizetOGOGAL.Pump Tank IC0CAL. t Trench Width 3(ellf Max.Trench Depth 2S �Rock Depth Linear Ft.3ED Site Modifications/Conditions/Other: CtA- �t-� Contact the Davie County Environmental Health Section for final i spection of this system between 8:30—9:30a.m.on the day of installation. Telephone#(336)751-8760. (�1 sys V- �T r a� f��>A 4o U 3?lZ ILI Environmental Health Special t Date: DCHD 11/06(Revised) —7/11110 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT Account M 990002128 Tax PIN/EH#: 5748-83-9141.18 Billed To: Phase IV Realty Subdivision Info: Marbrook Lot# 18 Reference Name: Location/Address: John Crotts Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 4698 i **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 Tank Date Tank Size Pump Tank Size System Installed By: E.H.Specialist: Date: 'r N l DCHD 11/06(Revised) nDD.., E C- E W E-IF�) 10ij APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC MAY 3 1 2007 Davie County Environmental Health P.O.Box 848/210 Hospital Street EaRONMENTAL HEALTH , Mocksville,NC 27028 DMECOUNTY (336)751-8760/Fax(336)751-8786 -Application For:NSite Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Type of Appli tion: Kew System 0Repair 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 Ci>tot c1 t Contact Person Billing Address P Home PhoneKly City/State/ZIP 1111 Business Phone Name on Permit/ATC if Di erent than Above . S�,r.Q, (FAX) Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged 3 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 Owner's Address City/State Zip Property Address a/� �'J o; City C Lot Size ax PIN o Subdivision Name(if applicable) Section/Lot# 0 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 ❑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 i IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms #Bathrooms Garden Tub/Whirlpooixes ❑No Basement: es ❑No Basement Plumbing: es ❑No I 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�Xonventional ❑Accepted ❑Innovative ❑Alternative ❑Other u' Water Supply Type- 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 11(No If yes,what type? 1 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 lit 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 EHS: Sign given ❑Yes ❑No Account# p�?Io2-? Revised 11/06 Invoice# Jun 04 07 07:03a Phase Iv RealtU (336) 748-1992 p. 3 4 . t �r � r5r E 50 r 1 d Y"j� NI G�rJ:J ot f ICAT�jOl; T F ITE EVALUATION/IMPROVEMENT PERMIT & ATC avie County Environmental Health �y0 P.O.Box 848/210 Hospital Street 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 Name to be Billed_ -6-"s� E=:f;A- _Qa,/Q 1, D,,,,,-}� Contact Person ne Billing Address_ �$ Hid X FJ / h Home Phone City/State/ZIP 4 .4 ,c �l/� 2--7yD 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—0611-3,'66)3 Owner's Address go / S�, l., City/State/Zip uc,,re-e.. AJC• Z wn�, Property Address ' •J�to vx C.,a s t1_ Cityl�Yly� ksv��IQ� Lot Size c5ee-x Jg Tax PIN# 67V Uifg1 q ,1ff Subdivision Name(if applicable) Section/Lot# Directions To Site: HSV (pc{ L '��- T��^•+ Cfv S �� S� � � 'c��-. c� `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 ❑No Does the site contain jurisdictional wetlands? ❑Yes lKo- Are there any easements or right-of-ways on the site? ❑Yes o Is the site subject to approval by another public agency? EYes ❑No Will wastewater other than domestic sewage be generated? ❑Yes Blgo IF RESIDEN E FILL OUT THE BOX BELOW �t�ee✓ T1> se r000ls #People #Bedrooms T #Bathrooms Z. Garden Tub/Whirlpool 0-Yes ❑No Basement: ❑Yes ❑No 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: ❑•Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other i Water Supply Type: County/City Water ❑New Well ❑Existing Well ❑ Community Well I I Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes D-N-0 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. J / Site Revisit Charge Property er' or own e legal representative signature Date(s): �- Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# gn3 Revised 11/06 G Invoice# i 1 . OHN Gl O1-7S t �4e A44 3 p � yJ4�'.r #, � � �X16 -r .,+ir- lh�ri� �'' �`=x�"-'��r � � Y•- _ �� � ' Mf JIMA) IP i vi. Nye d�.� ',.•' i �. It a>s �#�,mss�r t},',a d•Y>'_ =`. .r „:. 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DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account M 990004173 Tax PIN/EH M 5748-83-9141.18 i Billed To: Land First Development Subdivision Info: Marbrook Lot# 18 Reference Name: Rodney Bailey Location/Address: John Crotts Road-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: —A I I t D7 i i Water Supply: On-Site Well Community Public / Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position ---- Slope% D HORIZON I DEPTH Texture group CL_ L L I Consistence1 Structure ? Mineralogy %rluV HORIZON II DEPTH E Texture group C_ E Consistence Pr S4P i Structure f Mineralogy HORIZON III DEPTH 40 -4 O Texture group C-{ C;F Consistence ' S Structure < A� Mineralogy HORIZON IV DEPTH - Texture groupV Consistence 1 Structure # Mineralogy, l SOIL WETNESS C_ 1 RESTRICTIVE HORIZON L40 I SAPROLITE CLASSIFICATION S ps 1 LONG-TERM ACCEPTANCE RATE -Z7 0.L SITE CLASSIFICATION: Ps , EVALUATION BY: LONG-TERM ACCEPTANCE RATE: 11!2. OTHERS)PRESENT: REMARKS: �� �o'ITu.�la C-TP I$t3 LEGEND Landscape Position N 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 C 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 fret 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 Mineralo�v 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 05/05(Revised) f e Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 Account #: 990004173 IMPROVEMENT PER IN/EH M 5748-83-9141.18 Billed To: Land First Development Subdivision Info: Marbrook Lot# 18 Address: 228 NCHwy 801 North Location/Address: John Crofts Road-27028 City: Advance Property Size: see map Reference Name: Rodney Bailey j 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: J?<w ❑Repair ❑Expansion Permit Valid for: 05 Years PKo Expiration Residential Specifications: #Bedrooms #Bathrooms #People Basemen*8 asement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats pp' Square Footage(or Dimensions of F�ac�ility) k Design Flow(GPD): Type of Water Supply: }!ounty/City ❑Well ❑CommunityWell . Site Modifications/PermitConditions: M# 5�1� A� ulQra G SysternTypp LTAR Initial Repair C7•�7 Site Plan a C477 ,\, ilralnnQe And ox l tlttllt Easement r:� z cl N`03 39'31 E 265' 17q.58 ( o I - CA ,f � nAiQ S" Environmental Health Specialist Date Z O