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142 Aviation Way Lot 31 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/Fax #(336)753-1680 Account #: 990005528 Billed To: Sugar Valley Airport Reference Name: Proposed Facility: Residential ATC Number: 5106 OPERATION PERMIT Tax PINiEH #: 5851-26-8843.03 Subdivision Info: Sugar Valley Airport Lot # 3 Location/Address: Gilbert Road -27028 Property Size: 68 Acres **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC has been installed in compliance with Article I 1 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: I+O g S.T. Manufacturer hoc:Tank Date �', 1 Tank Size C) Pump Tank Size11 CAQQ System Installed By: C C%VM r elCaN'et-) E.H. Specialist: Date: GPS Coordinate: N -3 S� 9 • d 3 %' ' 0�d 3 O • '% 3 &f 5 P� tA, t �. r4, C, V�,+ y ` ay'M 83 X S/3CIl c� o -f Pte'"` e u � S G� "ko Cl- DCHD 11/06 (Revised) 17a0 -4 !4g` De ,is,o, L DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990005528 Tax PINrEH #: 5851-26-8843.03 Billed To: Sugar Valley Airport Subdivision Info: Sugar Valley Airport Lot # 3 Reference Name: LocationlAddress: Gilbert Road -27028 Proposed Facility: Residential Property Size: 68 Acres Site Type: ❑Kew ❑Repair ❑Expansion ATC Number: 5106 **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 D, # Bathrooms # People Ll Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) . L"J Lot Size 0• !Q %t? Type of Water Supply: ❑County/City Kell ❑CommunityWell ''11 d6 /10 System Specifications: Design Wastewater Flow (GPD))4(U Tank Size //Q GAL. Pump Tank GAL. Trench Width 3 G "'Max. Trench Depth 3 G / Rock Depth AO.A_ Linear Ft.- .7 41 I Site Modifications/Conditions/Other: a' 49ed LI -C.16 6 n Contact the Davie County Environmental B 8:30 — 9:30a.m. on the day of Environmental Health ,& P� _T fl�� a `t0 5't p1. C t.on for al inspection of this system betwei . final TcleDhone # (336)751-8760. r %t 41 cG I h,yra' 5,eyl.G J4-pe4 LN t A 1'-e 't .l� Date: DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/Fax #(336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990005528 Tax PINIEH #: 5851-26-8843.03 Billed To: Sugar Valley Airport Subdivision Info: Sugar Valley Airport Lot # 3 Reference Name: LocationiAddress: Gilbert Road -27028 Proposed Facility: Residential Property Size: 68 Acres ATC Number: 5106 .Site Type: K<e—w ❑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 chanee. Residential Specifications: # BedroomsX # Bathrooms 3 # People 4 Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility)F/� Lot Size Type of Water Supply: ❑County/City Well ❑Community Well System Specifications: Design Wastewater Flow (GPD) ��{� Tank SizeGAL. Pump Tank Py")GAL. Trench Width.? (o Max. Trench Depth Rock Depth Linear Ft. �y•� th't it Site Modifications/Conditions/Other: As stated in 15A NCAC 18A.1 69(5 7 loR'G0tC11_C — accepted Sys errs may a sr a risco �Ttlw- Contact the Davie County 8:30 — 9:30, .:re ruri,;y DCHD 11/06 (Revised) neealth Section for fir ieAay of ins n. Telepi �s tno;� of this system between i1-8760. Date: // / 5-- ( Q DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 OPERATION PERMIT Account #: 990005528 Tax PIN ',EH #: 5851-26-8843.03 Billed To: Sugar Valley Airport Subdivision Info:.- Sugar Valley Airport Lot # 3 Deference Name: LocationiAddress: Gilbert Road -27028 Proposed Facility: Residential Property Size: 68 Arrac Q.gZq 4G, ATC Number: 5106 **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: GPS Coordinate: DCHD 11/06 (Revised) Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax (336)753-1680 IMPROVEMENT PERMIT Account #: 990005528 Tax PIN/EH #: 5851-26-8843.03 Billed To: Sugar Valley Airport Subdivision Info: Sugar Valley Airport Lot # 3 Address: 249 Gilbert Road Location/Address: Gilbert Road -27028 City: Mocksville Property Size: 68 Acres Reference Name: Proposed Facility: Residential **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: ew ❑Repair• ❑Expansion Permit Valid for: [?5- ears ❑No Expiration Residential Specifications: # Bedrooms # Bathrooms 3— # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): a LA v Type of Water Supply: ❑County/City X11 ❑Community Well Site Modifications/Permit Conditions: As stated in 15A NCAG 1 _RA, 1 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 /Fax # (336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Accnunt #: 990005528 Billed To: Sugar Valley Airport Reference Narne: Proposed Facility: Residential ATC Number: 5106 Tax F KIEH #: 5851-26-8843.03 Subdivision Info:' Sugar Valley Airport Lot # 3 LocationiAddress: Gilbert Road -27028 Property Size: 68 Acres Site Type: 2Kew ❑Repair DExpansion **NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building pennit(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 ohlie intended use change. Residential Specifications: # Bedrooms 1�1# Bathrooms # People 4 Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) �l�is�i Lot Size Type of Water Supply: ❑County/City ell L1 Community Well O System Specifications: Design Wastewater Flow (GPD) �y C)Tank Size 0iAL. Pump Tank�GAL. It 0 4 I Trench Width L Max. Trench ISepth3 � Rock Depth Linear Ft. 3 "1 Site Modifications/Conditions/Other: Azo stated in 15A NCAC 18A.1969(5) 5 accupteu s rtes may also be used '1'e ✓�� Contact the Davie County Environmental Health Section for final inspection of this system b 8:41-9..P a.in. on.the_dav, of-installatian.. T-ele. hmu —#. (g );Z,5 �-700,, , _ _ too. Environmental Health Specialist DCHD 11/06 (Revised) 9P 11� . I L GI .41 tlQx-4i tk!._ Date: Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Account #: 990005528 Tax PIN/EH #: 5851-26-8843.03 Billed To: Sugar Valley Airport Subdivision Info: Sugar Valley Airport Lot # 3 Address: 249 Gilbert Road Location/Address: Gilbert Road -27028 City: Mocksville Property Size: 68 Acres Reference Name: Proposed Facility: Residential **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: ew ❑Repair ❑Expansion Permit Valid for: Gars ❑No Expiration Residential Specifications: # Bedrooms 91- # Bathrooms # People -!L Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type- # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): a 410_ Type of Water Supply: ❑County/City Aell ❑Community Well As stated in 15A NCAC 18A.1969(5) Site Modifications/Permit Conditions: arrppted 4vct-mc may bb usad System Type LTAR Initial % Repair C ©• 7 Site Plan e dr. •G� ' •tee r; v 040 oe LBO Environmental Health Specialist Date ` 1 i.p. 11-06 � . application For: iiySke 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 Billing Address " City/State/ZIP E Name on Permit/ATC if Different than Above Mailing Address PROPERTY INFORMA NOTE: A survey plat or site plan (Permit isalid for 60 01 Owner's Name �' Owner's Address ca Property Address Lot Size Subdivision Name(if applicable; To .� *Date accompany this application. vitt site plan,4io expiration N Tax PIN# _Contact Person.'f-'v1i� �--' Home Phone _ _Bush o Phhone 72-Z Comers Included: ❑ Site Plan ❑Plat(to scale) h complete plat.) Pho a Number i ,.-mss-- 7r _City/State/Zip6 �[�;�-�j _City Section/Lot# If the answer to any of the followi)(g questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? 11YesVN6-, Does the site contain jurisdictional wetlands? ❑Yes lido - Are there any easements or right-of-ways on the site? ❑Yes gRo J Is the site subject to approval by another public agency? ❑Yes ZkN6. Will wastewater other than domestic sewage be generated? ❑Yes IF RESIDENCE FILL OUT THE BOX BELOW # People I-' # Bedrooms — # Bathrooms Garden Tub/Whirlpool ❑Yes glo Basement: ❑: Ye� Basement Plumbing: ❑ Yes UWc r - 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: 9Conventional ❑Accepted ❑Innov-ave ❑Alternative ❑Other Water Supply Type: ❑ County/City Water r4ew 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? 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' d rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and va loand flagging o ng tlWhouse/facility location, proposed well location and the location of any other amenities. Site Revisit Charge roperty owner's or owner's legal representative signature Date(s): Client Notification Date: 1 f DAVIE COUNTY HEALTH DEPARTMENT - Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit / PROPERTY INFORMATION Lot 3 Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope % HORIZON I DEPTH Ci C1— Texture group 5e- L G Consistence SSsP .7 StructureOL #34L h Mineralogy V HORIZON II DEPTH - / .- 3 Texture group G 5Gv 541, ' )r Consistence VidSUAIr 0-5 Structure E aC Mineralogy _51641.0 HORIZON III DEPTH 7F7qq 3— -33— �0 Texture Texture rou LL Consistence S Structure CIO .51,07 MineralogyS HORIZON IV DEPTH yq_je3y T — Texture group -5 e— 5, L Consistence Structure V C V Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE ./1 40.1 7 — SITE CLASSIFICATION: 15 LONG-TERM ACCEPTANCE RATE: Pdffilr5l REMARKS: LEGEND EVALUATION BY iv 'l � o/�f`� -G"Jr't'< OTHER(S) PRESENT. (i SC[ 0 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 m St VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm 3yet 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 Mineralogy 1:1, 2:1, Mixed Notes 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 05105 (Revised)