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183 Marbrook Dr Lot 22 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT Account #: 990003908 Tax PIN/EH#: 5748-83-9141.22 Billed To: Mark Davis Subdivision Info: Marbrook Lot#22 Reference Name: Location/Address: Proposed Facility: Residence Property Size: See Map ATC Number: 4683 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. g� �- System Type:-= S.T.Manufacturer 3I' 80 Tank Date Tank Size Pump Tank Size System Installed By: `s � ' (I.H.Spec' ist: /O �o 0 -2 JLC CAA IA 3 �9 u S Zr PCO r DCHD 11/06(Revised) ' 1 I 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 990003908 Tax PIN/EH M 5748-83-9141.22 Billed To: Mark Davis Subdivision Info: Marbrook Lot#22 Reference Name: Location/Address: Proposed Facility: Residence. Property Size: See Map ATC Number: 4683 Site Type:,,2<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 . #Bathrooms 3 #People Basement❑ Basement plumbin;Z'O" Non-Residential Specifications: Facility Type #People #Seats 2� Square Footage(or Dimensions of Facility) Lot Size /" Type of Water Supply: i3County/City ❑Well ❑CommunityWell System Specifications: Design Wastewater Flow(GPD) 5� Tank Size I LAL.Pump Tank GAL. 11 40-1),Trench Width Max.Trench Depth �� Rock Depth Linear Ft. Site Modifications/Conditions/Other: s Yqgt� 1 S 9,rP %___W 10 1 COE YQiF, L-1 A& Contact the Davie County Environmental Health Section for final inspection of this system between 77e :30—9:30a.m.on the day of installation. Telephone#(336)751-8760. 10,1 1 I W Ilam` � 14 v1vE Environmental Health Specia st Date: 677 DCHD 11/06(Revised) I SITE EVALUATION/IMPROVEMENT PERMIT & ATC ! Davie County Environmental Health O 2001 P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 Ap icati cJ� p"d � ' ion/Improvement Permit Authorization To Construct(ATC) ❑ Both Typ of Applicat ew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility I ***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 M 4.0 K 0 �4 Vi.,%a Contact Person Billing Address -TT t•r O Home Phone City/State/ZIP g /Ail c,_y �1,t C )—:2,0 O,F 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 Phone Number Owner's Address City/State/Zip Property Address City Lot Size Tax PIN# Subdivision Name(if applicable) o Sectign/Lot# Directions To Site: _ 6y �= •r© 1214A, -6; t / �( If the answer to any of the following questions is"yes",supporting documentatio�ust be attached. Are there any existing wastewater systems on the site? ❑Yes Ro Does the site contain jurisdictional wetlands? ❑Yes Are there any easements or right-of-ways on the site? ❑Yes Is the site subject to approval by another public agency? ❑Yes Will wastewater tither than domestic sewage be generated? ❑Yes ZNo o IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms Pathrooms Garden Tub/Whirlpool 9 es ❑No Basement: es ❑No Basement Plumbing: DX'es ❑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; VConventional ❑Accepted ❑Innovative ❑Alternative ❑Other I Water Supply Type: ❑.bounty/City Water ❑New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑No If yes,what type? I, 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 stakinUb�eh se/faci ' oc 'on,proposed well location and the location of any other amenities. Site Revisit Charge Property&Vner's or owner's legal representative signature Date(s): Client Notification Date: Dat EHS: Sign given ❑Yes ❑No Account# Ub Revised 11/06 Invoice# ' i! EV Q ICAT Q T F ITE EVALUATIONAMPROVEMENT PERMIT & ATC O 4J avie County Environmental Health P.O.Box 848/210 Hospital Street \MEP�NFA�ZN Mocksville,NC 27028 (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 CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed jC y,s� E-:r;A- DQ ire Contact Person Billing Address �.,�$ H&, X !F-11 6",-J h Home Phone City/State/ZIP 14&t,.,,4 .4�. Business Phone �d - 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 Z VA-1 .--,e ., Phone Number �� Owner's Address go / City/State/Zip_ L C,,-e-e- A-4C. 2- 2,20(o Property Address s^ �1_ City 4,140>(- vi1/'z� Lot Size c5ee-in q::o Tax PIN# Subdivision Name(if applicable^` ) � -O_k Section/Lot# ?-Z- Directions To Site: HL�3 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 0355 Does the site contain jurisdictional wetlands? ❑Yes 01qo— Are there any easements or right-of-ways on the site? ❑Yes �o Is the site subject to approval by another public agency? e0Y s ❑No Will wastewater other than domestic sewage be generated? DYes RN-6- 4L- E /Q u 3 i�mS IF RESIDEN E FILL OUT THE BOX BELOW #People #Bedrooms 4 #Bathrooms ' Garden Tub/Whirlpool 3-Yes ❑No Basement: ❑ es EN. 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: CrC75—hventional ❑Accepted ❑Innovative ❑Alternative ❑Other FF Water Supply Type: CCounty/City Water ❑New Well OExisting Well ❑ Community Well r Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 3-N-0 If yes,what type? This is to certify that e 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. -7,e,,Z,7 Site Revisit Charge Property er' or owne legal representative signature Date(s): �— ,,2 Client Notification Date: { Date EHS: Sign given ❑Yes ONo Account# q1 73 Revised 11/06Invoice# Z I r-%I i Ni m r"171T C Q n 4753 Ar r � r C r{p ?.��� �?�a ye ,{ 'r i� ,,.� �p�� f,• _ 4 ,'`t i. ��. t^Y f' � t 3 ems' ,. t ��, 1 !! t.'l y�i 1 �aY� r'Y t - ... 'A� ��' •�r. <. (. 2tz 4 41 i^r v Yr {•.4 _.'� s. ,� '.i # q9�r at A Is ' t - 4 01t iL•3 .: � afia � ..: iii .G "�i .�,a�• �..�,.I i��� � i' r :� • tT q ,J 4e �i•1'ts, s�y gi f�j � � R,�'{i6gt�tl "�T �+'¢� � •d/•� a �t11 G1A1 yx�< ! ! a .# 3 zµ v JOHN CROTTS RD 4763 - �o a 1 ,:,a17 yai602 _.:pHNCWTTSMAO ,,... X64' vo ryo ���46 8331 Nol (3943� 00 PaD GnB s ho N (3.97 Al 7210 614b 1,n Q1 F31 9141 CeB2 j -� 1081 1 t. (1.81A f' 63 co I ve }'PANS', it PcC2 ►' 4 GaD CeB2 ; co N 1 W Q 6144 GnC2 l N ► GnB2 i 7617 JJ6� � 1 f i ', •. - , • �r 1` rte' '`� ... - \ _ - !: df. 'yl X71.. J� z rj N , r d �n fes• ..� � � ..-� o . �'N , ����� I ` r 15�1 15 M 20 125' Lo --• Ipo S aJ �^•t \ _V.` Ln T N 4u -r co N ,{ t -__.. , i/ �✓' jr `.CR i'- Si �Rl,�-tJN :';JAa • DAME COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990004173 Tax PIN/EH#: 5748-83-9141.22 Billed To: Land First Development Subdivision Info: Marbrook Lot#22 Reference Name: Rodney Bailey Location/Address: John Crotts Road-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: Cy") I , Water Supply: On-Site Well Community Public Evaluation By: Auger Boring pamr Cut FACTORS 1 2 ) 3 4 5 6 7 Landscape position L L L' Sloe% 5�0 Z S70 HORIZON I DEPTH p O- p- o = (P Texture group 0A_ Consistence Pr m3P S Structure CV_ Mineralogy HORIZON II DEPTH r 31 r!- -- 1 -It -•116 Texture group C 0— ►(-1 G E Consistence vpo/ Structure A;5 S V, Mineralogy L- tiL- HORIZON III DEPTH a- -3 1.2 D 10- Texture group Cfi Ck_ CtSa 5,,C+.Sod Consistence E Structure WPO4 pae, Mineralo 5v ot- P 7fXSW M HORIZON IV DEPTH 'Z fi p Texture group 4&0 G 1 S.•i C-t Consistence ; r Structure L Mineralogy SOIL WETNESS Z3 jd'. t_ c CulCsUe.. RESTRICTIVE HORIZON4� 7 3�fli 3 3Z J SAPROLITE — V CLASSIFICATION us S S LONG-TERM ACCEPTANCE RATE E O ,�E SITE CLASSIFICATION: I°S EVALUATION BY. Aa- --P e;1�kA'NT LONG-TERM ACCEPTANCE RATE: e_2.2.75' OTHER(S)PRESENT: REMARKS: i LI _ AA07f AG C- 4p LEGEND Landscape Position R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope P 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 CONSTSTENCF, lY1Qist VFR-Very friable FR-Friable FI-Firm VFI-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 j Structure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky r SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogy 1:1,2:1,Mixed ZYut� 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) +' 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#: 5748-83-9141.22 Billed To: Land First Development Subdivision Info: Marbrook Lot#22 Address: 228 NC Hwy 801 North Location/Address: John Crotts Road727028 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: ,clew ORepair ❑Expansion Permit Valid for: 05 Years o Expiration Residential Specifications: #Bedrooms S #Bathrooms 2 #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats r Square Footage(or Dimensions of Facility) Design Flow GPD : f g ( ) � Type of Water Supply: ❑Well ❑Community Well Site Modifications/Permit Conditions: System Type LTAR Initial tom. ©,22S- Repair 2Re air 'l Q, Site Plan Ila 'U ji Al V ' ) 4D Environmental Health Specialist i.p.11-06