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182 Marbrook Dr Lot 19 • 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 990002706 Tax PIN/EH M 5748-83-9141.19 Billed To: Jeff Hayes Subdivision Info: Marbrook Lot# 19 Reference Name: Location/Address: Proposed Facility: Residence Property Size: see map ATC Number: 4685 **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 DatTank Size Pump Tank Size IA System Installed By:Baan r11l�l na'<<( E.H.Specialist: ate: o�0/6 f G (4�N3` DCHD 11/06(Revised) n� ' 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 990002706 Tax PIN/EH M 5748-83-9141.19 Billed To: Jeff Hayes Subdivision Info: Marbrook Lot#19 Reference Name: Location/Address: Proposed Facility: Residence_ Property Size: see map ATC Number: 4685 Site Type:.,.?<Cw ❑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 plumbinge Non-Residential Specifications: Facility Type #People #Seats J Square Footage(or Dimensions of Facility) Lot Size 3-70'S_-7 Type of Water Supply. unty/City ❑Well ❑CommunityWell System Specifications: Design Wastewater Flow(GPD) -IA�Tank Size�nwGAL.Pump Tank GAL. Trench Width 3k�' Max.Trench Depth SJ Rock Depth IN Linear Ft. , Site Modifications/Conditions/Other: "I) Contact the Davie County Environmental Health Section for fi al inspection of this system between 8:30—9:30a.m.on the day of installation. Telephone#(336)751-8760. EJECA(0") 70 , r 60, R� Z43 o . ti Environmental Health Specialist Date: !7 DCHD 11/06(Revised) v APP SITE EVALUATIONAMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 A plication Fora_-_..p ite 9 tion/I vement Permit ❑ Authorization To Construct(ATC) ❑ Both T e of p�a RR+�71`l` em ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility �t,1 * RTANT***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 41� C4ontact Person Billing Address — vJ Home Phone City/State/ZIP . , /.A usiness Phone Name on Permit/ATC if Different than Above S} ` _ 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 Owner's Address City/State/Zip Property Address Lot Size Tax P Subdivision Nameif applicable) #I r< =— ot# Directions To Site: c ' 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 d o Does the site contain jurisdictional wetlands? ❑Yes[No o Are there any easements or right-of-ways on the site? Dyes Is the site subject to approval by another public agency? ❑Yeso Will wastewater other than domestic sewage be generated? ❑Yeso IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms #Bathrooms Garden Tub/Whirlpool Dyes ❑No Basement: es ❑No Basement Plumbing: es ❑No . IF NON-RESIDENCE FILL OUT THE B :. T e of FacilityBusiness Total Square Footage of Building #People #Sinks ede #Showers #Urinals Estimated r sage(gallons per day) (Attach documentation of similar facility water consumption) SERVICE ONLY: #Seats I� Type system requested; ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other —k 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 Vo 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,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 r owner's epresentative signature Date(s): Client Notification Date: Date . EHS: p P Sign given Dyes ❑No Account# 77I //-�-\Revised 11/06 Invoice# Vv CAT�OAI F ITE EVALUATION/IMPROVEMENT PERMIT & ATC "' avie County Environmental Health P.O.Box 848/210 Hospital Street ENjP�HtA�Tt1 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 Billedh� E-:r;�- (�Q��e p,,�,T Contact Person ney -Billing Address Home Phone City/State/ZIPS. .� �,� �f lam( Z-7yD12 _Business Phone (S - 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: Elite Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name PhoneNumber Owner's Address go/ S�, !�, City/State/Zip �7t�LC, e- �U C. Z ]v o Property Address A/li_ City Lot Size ce-e—in Tax PIN# -7V 0%9?7/q1/,/9 Subdivision Name(if applicable) r yk Section/Lot# ti Directions To Site: HL-3V (n(4 L '� �'��^++ Cr v �tl. SL, 4J v;s c d L 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 ❑N-6 Does the site contain jurisdictional wetlands? ❑Yes ❑11ro Are there any easements or right-of-ways on the site? ❑YYes-�o Is the site subject to approval by another public agency? eE3Y s []No Will wastewater other than domestic sewage be generated? ❑Yes 0156— 4 lk IF RESIDEN E FILL OUT THE BOX BELOW J' #People - #Bedrooms �— #Bathrooms Garden Tub/Whirlpool BY-es ❑No Basement: ❑ es ❑No Basement Plumbing: ❑Yes ❑No �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 i Type system requested: ErConventional ❑Accepted ❑Innovative ❑Alternative ❑Other 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 0-50— If 3—If yes,what type? 00.s &eZ1-,CJc,/1 JH724 V4- CCS 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 comers 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: j • I Sign given ❑Yes []No /1 Account# Revised 11/06 ��1 Invoice# i J q "AUC Dr - �t F,es-`isZv+..�.� ✓+a s�- .�, _ -7Ri '-7�� is e. 7648-o v- t...� -ve` HX.;".'XA ,yy, . r � lo ,'" y ear r{7} 4e t s.4.x,tk=�,• ,,rK,: #+ '47Y` �.�` .- _ .� rl� 17 _�� •'�,},�,. Y v� ,. 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LiiS FOAL 1*17(I7B1 a3 \, {1.WA) \ � `� p PaD G n B A 'A 32 \ i 6149 %( �o � �GC� 401 f11� 9141 1 S� CeB2 / o 1081 1 (1 w 00 flnw PcC2 GaD CeB2 00 1 160 I W Q (16.464, 1 6144 GnC2 l N GnB2 � s \ 7617 bV J)J 154 i '0 � rr9^^54Ei - to W 1 l9 3 7A f�7 19 c.1 M, too ,N I t m N i ./n / z : + � CP b . lJ f i ' Q ' hl Pit r r 3 \2d i o� � �� TN a /7�N a's . DAVIE COUNTY HEALTH DEPARTMENT - Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION I Account #: 990004173 Tax PIN/EH#: 5748-83-9141.19 Billed To: Land First Development Subdivision Info: Marbrook Lot#19 Reference Name: Rodney Bailey Location/Address: John Crotts Road-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: ho c Water Supply: On-Site Well Community Public C Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L !_ Slope% HORIZON I DEPTH Texture group Consistence Structure Mineralogy 1 HORIZON H DEPTH 2f>-14 Is- Texture group Consistence i Structure ! Mineralogy Sim HORIZON Ill DEPTH Texture group Consistence i Structure I Mineralo 1 HORIZON IV DEPTH Texture groupI Consistence I Structure I Mineralogy SOIL WETNESS RESTRICTIVE HORIZON I SAPROLITE I CLASSIFICATION S f LONG-TERM ACCEPTANCE RATE ? O. J O• f IQ SITE CLASSIFICATION: P S EVALUATION BY: "�J LONG-TERM ACCEPTANCE RATE: fl'Z"�� OTHER(S)PRESENT- f REMARKS: 1 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 MQiSt VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm 33'et • • 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 I SBK-Subangular blocky PL-Platy PR-Prismatic Mix 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-galtday/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#: 5748-83-9141.19 Billed To: Land First Development Subdivision Info: Marbrook Lot# 19 Address: 228 NC Hwy 801 North Location/Address: John Crotts Road-2. 7028 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. Pennit Type: „0 iew ❑Repair ❑Expansion Permit Valid for: 0 Years 0<0 Expiration Residential Specifications: #Bedrooms,--5 #BathrooMS 2- #People Basemenj;;iogasement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): Type of Water Supply: unty/City ❑Well ❑Community Well Site Modifications/Permit Conditions: POMP 0cPu1REP $ stem Type LTAR Initial + Repair Site Plan 1 j ��- , . oma`' OA Environmental Health Specialist a (o O7 i.p.l 1-06