184 Marbrook Dr Lot 20 I
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Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760/Fax(336)751-8786
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IMPROVEMENT PERMIT
Account M 990004173 Tax PIN/EH#: 5748-83-9141.20
Billed To: Land First Development Subdivision Info: Marbrook Lot#20
Address: 228 NC Hwy 801 North Location/Address: John Crofts Road 27028
City: Advance _ Property Size: see map
Reference Name: Rodney Bailey
Proposed Facility: Residence
** ** e e construction of a wastewater system. An
NOTE This Improvement Permit DOES NOT authorize th o struction st
P Y
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 pennit(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: ew ❑Repair ❑Expansion Permit Valid for: 0 Years o Expiration
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Residential Specifications: #Bedrooms 3 #Bathrooms#People-Basement�asement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD) Type of Water SupplyXunty/City ❑Well ❑CommunityWell
Site Modifications/Permit Conditions: 0�+��
X= —€J M G. —C
System Type LTAR C
Initial — 'N'
Repair LE� a-Z'7
Site Plank \ -r .
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Environmental Health Specialis JDDate [ca
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i.p.11-06
ICATtON F ITE EVALUATION/IMPROVEMENT PERMIT & ATC
avie County Environmental Health
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
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***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 (c,,_ .-;A- 17Q 11e<<, p,.,�-�' Contact Personb�
Billing Address $ Hoy '?J I s&J-b Home Phone
City/State/ZIP 44&(.,1 �4 C a/C Z 2QQb Business Phone
Name on Permit/ATC if Different than Above k
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Comers 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 ,-, V , Phone Number 001 -3se)3
Owner's Address Sol City/State/Zip /,,c,�c¢_ AJC. Z 2630(c,
PropertyAddress �G►r� C.ro (�,�1_ City
Lot Size c522-In4q p Tax PIN#_ -5-7V ai?g1q/,-Z0 c
Subdivision Name(if applicable)) Section/Lot# ZZ�
Directions To Site: ht,3V 04 L t- 7'IL^►r, Cee W�.
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 Blgo-
Are there any easements or right-of-ways on the site? oyes- o
Is the site subject to approval by another public agency? ffies ❑No
Will wastewater other than domestic sewage be generated? ❑Yes BN-o —
IF RESIDEN E FILL OUT THE BOX BELOW Xi e
#People - ' #Bedrooms '4V #Bathrooms 7-- Garden Tub/Whirlpool BTes ❑No
Basement: ❑Yes ❑No Basement P"luur bing: ❑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
Type system requested: ❑'Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: CJ-'C"ounty/City Water ❑ New Well ❑Existing Well ❑ Community Well
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Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 3'1q-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.
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Site Revisit Charge
Property er' or own e legal representative signature
Date(s):
j�- ;2 Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account# y/73
Revised 11/06 �� r Invoice#
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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 5748-83-9141.20
Billed To: Land First Development Subdivision Info: Marbrook Lot#20
Reference Name: Rodney Bailey Location/Address: John Crotts Road-27028
Proposed Facility: Residence Property Size: see map Date Evaluated: " b')
Water Supply: On-Site Well Community Public
Ey l luation By: Auger Boring Pit / Cut
i' FACTORS 1 2 3 4 5 6 7
Landscape position I- L
Sloe% 1070
HORIZON I DEPTH 0 `7 O -Le
Texture group G
Consistence
Structure
Mineralogy
HORIZON H DEPTH '?
Texture group
Consistence
Structure r—
Mineralogy
HORIZON II1 DEPTH LAT,5 - Q
Texture group r LS
Consistence `
Structure
1%z-
Mineralogy
HORIZON IV DEPTH
Texture group (--
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE - S
CLASSIFICATION S
LONG-TERM ACCEPTANCE RATE 01 27 tom•3
SITE CLASSIFICATION: EVALUATION BY:
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LONG-TERM ACCEPTANCE RATE: Z1 OTHER(S)PRESENT:
REMARKS
LEGEND
Landseape 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 Sl-Silt
SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC Sandy clay SIC-Silty clay C-Clay
CONSISTENCE
),'1415>i
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
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Structure
SC;Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
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Mineralogy
1:1�2:1,Mixed
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Horizon depth-In inches
Depth of fill-In inches
Restrictive horizon-Thickness and inches from land surface
Sapcolite-S(suitable),U(unsuitable)
Soii 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)
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