247 Gilbert Road Lot 1DAVIE 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
Billed To: Sugar Valley Airport
Reference Name: Susan Park
Proposed Facility: Residence
Tax PINIEH #: 5851-26-8843.1
Subdivision Info: Sugar Valley Airport Lot #
LocationlAddress: 249 Gilbert Road -27028
Property Size:,1,031 Acres
Site Type: New ❑Repair ❑Expansion
ATC Number: 5105
**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 # People Basement[] Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility) .
Lot Size (. / Type of Water Supply: ❑County/City WVell ❑CommunityWell
System Specifications: Design Wastewater Flow (GPD) i � 6 Tank Size VAL. Pump TankAo— GAL.
J.
Trench Width 7:3�a Max. Trench Depth�v � Rock DepthLinear Ft.3�?'r� 0-P
Site Modifications/Conditions/Other: a 5Z Aeede- c !•�
Contact the Davie County Environmental Health Section for final inspection of this system between
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
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #:
990005528
Billed To:
Sugar Valley Airport
Reference Narne:
Susan Park
Proposed Facility:
Residence
Tax PIN:EH #: 5851-26-8843.1
Subdivision Info:,-, Sugar Valley Airport Lot
LocationiAddress: 249 Gilbert Road -27028
Property -Size: 1.031 Acres
ATC Number: 5105 ,Site Type: EXtiw� ❑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 # People Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type #People # Seats
Square Footage(or Dimensions of Facility) SS
Lot Size el �QCt
�_ 031 Type of Water Supply: ❑County/City o munity Well
System Specifications: Design Wastewater Flow (GPD) ank Size OnPAL. Pump Tan►c �4GAL.
Trench Width _ Max. Trench Depth Rock Depth i n e a r Ft..
Site Modifications/Conditions/Other: 7 _ 1;— � tor.4 LJLc: )6
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30 — 9:39a.yh. on the day of installation. Telephone 36 7518760._
Environmental Health Specialist_=�?�G
DCHD 11/06 (Revised)
0
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 PILI./EH #: 5851-26-8843.1
BilledTo: Sugar Valley Airport Subdivision Info:. Sugar Valley Airport Lot #
Reference Name: Susan Park LocationiAddress: 249 Gilbert Road -27028
Proposed Facility: Residence . Property Size: 1.031 Acres
ATC Number: 5105
**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.
Pump Tank Size
System Installed By:
GPS Coordinate:
DCHD 11/06 (Revised)
Tank Date Tank Size
E.H. Specialist: Date:
iGation For: mite Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both
Type of Application: ❑New System DRepair to Existing System DExpansion/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
14
Name to be Billed YG% (- 0 Contact Person
Billing Address Home Phone _C -t c� -7
City/State/ZIP P 7'
Name on Permit/ATC if Different than Above
Mailina Address Citv/State/Zin
PROPERTY INFORMATION
*Date House/Facility Corners
NOTE: A survey plat or site plan must accompany this application.
(Permit is valid for 60 months Vnith site plan, inexpiration v
Owner's Name J
Owner's Address led T
Property Address
Lot Size Tax PIN#
Subdivision Name(if applicable)
Directions To Site: ilL, .i P .-F r
Included: 9b' ite Plan DPlat(to scale)
h complete plat.)
-- Phone Number �7 -
City
If the answer to any of the follo(ving 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? Dyes UM
Are there any easements or right-of-ways on the site? ❑Yes y
Is the site subject to approval by another public agency? ❑YesGN o -
Will wastewater other than domestic sewage be generated? ❑Yes i7ddo
IF RESIDENCE FILL OUT THE BOX BELOW
# People# Bedrooms_ # Bathrooms ' y- Garden Tub/Whirlpool DYes No
Basement: ❑Yes '�o Basement Plumbing: DYes Xo
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: 3/conventional ❑Accepted ❑Innovative DAlternative ❑Other
Water Supply Type: ❑ County/City Water D New Well 'Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes
If yes, what type?
XNo
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
lova ' g and flagging ors the se/facility location, proposed well location and the location of any other amenities.
P o rty owner's or owner's legal representative signature Site Revisit Charge
Date(s):
Client Notification Date:
Zs�
' DAVIE COUNTY ENVIRONMENTAL HEALTH
.P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680
OPERATION PERMIT RY I (Ydbefi4l
Account #:
990005528
Tax PINiEH #:
5851-26-8843.1
/subdivision
Billed To:
Sugar Valley Airport
Info:
Sugar Valley Airport Lot #
Reference Narne:
Susan Park
LocationfAddress:
241 Gilbert Road -27028
Proposed Facility:
Residence
Property Size:
1.031 Acres
ATC Number: 5105 % /j 000 W.5-
**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.
-t�
System Type: % S.T. Manufacture rS� Tank Date — Ta Size
Pump Tank Size ,n
System Installed By:s,\ C. •n. Aa.ti.- -H. Specialist.401— A Dater,
GPS Coordinate:
DCHD 11/06 (Revised)
P.O. Box 8047
North Carolina State Laboratory of Public Health 06 N. Wilmington St.
Environmental Sciences Raleigh, N 27611-8047
hftp:/lslph.ncpublichealth.com
Inorganic Chemistrym-
Certificate of Analysis f7 aXL-Qa2WD
NOV 0 3 2011
Report To: ANDREW DAYWALT Name of System:
DAVIE CO ENVIRONMENTAL HEALTH
SUGAR VALLEY AIRPORT
P O BOX 848 249 GILBERT RD, LOT #
MOCKSVILLE, NC 27028 Courier # 09-40-06 MOCKSVILLE, NC 27028
EIN: 566000295EH
StarLiMS ID: ES102511-0035001 Date Collected: 10/24/11 Time Collected: 11:15 AM
Date Received: 10/25/11 Collected By: Andrew Daywalt
Sample Type: Sampling Point: Well head Well Permit #:
Sample Source: New Well Temp. at Receipt: 7.0 GPS #:
Sample Description:
Comment: No permit # given with sample.
New Well I (Profile)
Analyte
Result
Allowable Limit
Unit Qualifier(s)
Arsenic
< 0.005
0.010
mg/L
Barium
< 0.1
2.00
mg/L
Cadmium
< 0.001
0.005
mg/L
Calcium
47
mg/L
Chloride
6.40
250
mg/L
Chromium
< 0.01
0.10
mg/L
Copper
< 0.05
1.3
mg/L
Fluoride
< 0.20
2.00
mg/L
Iron
< 0.10
0.30
mg/L
Lead
< 0.005
0.015
mg/L
Magnesium
10
mg/L
Manganese
< 0.03
0.05
mg/L
Mercury
< 0.0005
0.002
mg/L
Nitrate
< 1.00
10.00
mg/L
Nitrite
< 0.10
1.00
mg/L
pH
8.0
N/A
Selenium
< 0.005
0.05
mg/L
Silver
< 0.05
0.10
mg/L
Sodium
13.00
mg/L
Sulfate
28.00
250
mg/L
Total Alkalinity
147
mg/L
Total Hardness
160
mg/L
Zinc
< 0.05
5.00
mg/L
Report Date: 11/01/2011
Page 1 of 1
Reported By: %%ilk x4y
North Carolina State Laboratory Public Health P.O. Box 28047
' 1 306 N. Wilmington St.
Environmental Sciences Raleigh, NC 27611-8047
http://slph.ncpublichealth.com
Microbiology Phone: 919-733-7834
1 JZ3r8Q95
Certificate of Analysis ROCE
NOV 0 3 2011
Report To: Name of System:
DAVIE CO ENVIRONMENTAL HEALTH
SUGAR VALLEY AIRPORT
P O BOX 848 249 GILBERT RD, LOT #
MOCKSVILLE, NC 27028 MOCKSVILLE, NC 27028
EIN:566000295EH COURIER #: 09-40-06
StarLiMS Sample ID: ES102511-0072001 Collected: 10/24/2011 11:15 Andrew Daywalt
111111111111111111111111111111111111111111111 11111111111111111111111 Received: 10/25/2011 08:50 Angela Heybroek
ES Microbiology ID: 31488 Sample Source: New Well Well Permit Number:
GPS Number: Sampling Point: Well head
Sample Description:
Comment: No permit # given with sample.
Environmental Microbiology - Colilert Profile Method: SM 92238
Test Name: Colilert
Analyte Test Result Analyst Date
Total Coliform, Colilert Absent Susan Beasley 10/26/2011
E. coli, Colilert Absent Susan Beasley 10/26/2011
Report Date: 10/28/2011 Reported By: Susan Beasley
Explanations of Coliform Analysis:
If coliform bacteria are Absent, the water is considered safe for drinking purpose. If coliform bacteria are Present,
the water is considered unsafe for drinking purpose. Presence of E. coli (bacteria) generally indicates that the water
has been contaminated with fecal material. It must be remembered that a water analysis refers only to the sample
received and should not be regarded as a complete report on the water supply.
P.O. Box 8047
North Carolina State Laboratory of Public Health 06 N. Wilmiington St.
Environmental Sciences Raleigh, NC 27611-8047
http://slph.ncoublichealth.com
Inorganic Chemistry Phone: 919-733-7834
Fax: 919-733-8695
Certificate of Analysis
RECEIVED
Report To: ANDREW DAYWALT Name of System:
NOV 0 3 2011
DAVIE CO ENVIRONMENTAL HEALTH
SUGAR VALLEY AIRPORT
P O BOX 848 249 GILBERT RD, LOT # 1
MOCKSVILLE, NC 27028 Courier # 09-40-06 MOCKSVILLE, NC 27028
EIN: 566000295EH
StarLiMS ID: ES102511-0036001 Date Collected: 10/24/11 Time Collected: 11:00 AM
Date Received: 10/25/11 Collected By: Andrew Daywalt
Sample Type: Sampling Point: Well head Well Permit #: 68
Sample Source: New Well Temp. at Receipt: 6.0 GPS #:
Sample Description:
Comment:
New Well I (Profile)
Analyte
Result
Allowable Limit
Unit Qualifier(s)
Arsenic
< 0.005
0.010
mg/L
Barium
< 0.1
2.00
mg/L
Cadmium
< 0.001
0.005
mg/L
Calcium
42
mg/L
Chloride
5.30
250
mg/L
Chromium
< 0.01
0.10
mg/L
Copper
< 0.05
1.3
mg/L
Fluoride
< 0.20
2.00
mg/L
Iron
< 0.10
0.30
mg/L
Lead
< 0.005
0.015
mg/L
Magnesium
12
mg/L
Manganese
< 0.03
0.05
mg/L
Mercury
< 0.0005
0.002
mg/L
Nitrate
< 1.00
10.00
mg/L
Nitrite
< 0.10
1.00
mg/L
pH
7.7
N/A
Selenium
< 0.005
0.05
mg/L
Silver
< 0.05
0.10
mg/L
Sodium
10.00
mg/L
Sulfate
25.00
250
mg/L
Total Alkalinity
146
mg/L
Total Hardness
150
mg/L
Zinc
< 0.05
5.00
mg/L
Report Date: 11/01/2011
Page 1 of 1
Reported By: ?&& Zl,�cg
P.O. Box 28047
North Carolina State Laboratory Public Health 306 NWilmington St.
Environmental Sciences Raleigh, NC 27611-8047
http://slr)h.nc[)ublichealth.com
Microbiology Phone: 919-733-7834
P�a�!T695
Certificate of Analysis --
NOV 0 3 2011
Report To: Name of System:
DAVIE CO ENVIRONMENTAL HEALTH
SUGAR VALLEY AIRPORT
P O BOX 848 249 GILBERT RD, LOT # 1
MOCKSVILLE, NC 27028 MOCKSVILLE, NC 27028
EIN:566000295EH COURIER M 09-40-06
StarLiMS Sample ID: ES102511-0073001
11111111111111 I I 11111111111111111111111111111111111111111111111111111111111111111111111111
ES Microbiology ID: 31489
GPS Number:
Sample Description:
Comment:
Environmental Microbiology - Colilert Profile
Collected: 10/24/2011 11:00
Received: 10/25/2011 08:50
Sample Source: New Well
Sampling Point: Well head
Andrew Daywalt
Angela Heybroek
Well Permit Number:
68
Method: SM 92238
Test Name: Colilert
Analyte Test Result Analyst Date
Total Coliform, Colilert Absent Susan Beasley 10/26/2011
E. coli, Colilert Absent Susan Beasley 10/26/2011
Report Date: 10/28/2011
Explanations of Coliform Analysis:
Reported By: Susan Beasley
If coliform bacteria are Absent, the water is considered safe for drinking purpose. If coliform bacteria are Present,
the water is considered unsafe for drinking purpose. Presence of E. coli (bacteria) generally indicates that the water
has been contaminated with fecal material. It must be remembered that a water analysis refers only to the sample
received and should not be regarded as a complete report on the water supply.
DAVIE COMMIT HEALTH DEPARTD-MUT
PERCOLATION TEST RESULTS
DATE
NAIME
'-
,�� -;;> �f %
FINDINGS:
HOLE 140.
1
2
3
4
5
M
V-
CONMELI S ,/
/,cKeel-/- //Wc live
LOT DIAGIWI •-T'"q � � QP,
JW1,
DAVIE COUNTY HEALTH DEPARTMENT-
P. 0. BOX 57//
FiOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or -.Site Evaluations
NAIVE C�"�asJ!''/' P DATE ISSUED
ADDRESS /1 4� PERMIT NO.
;zr ,!
Explanation of charge
DD
AMOUNT DUES SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.
r DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name -- Date
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business __ Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑
s
Auto Wash Machine YES Ey" NO ❑
Type Water Supply
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit by
`Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System
/ f
,,
Certificate of Completion's Date
'The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
Tax Lot 4.04
Tax Map E-6
n/f Denise Cynthia Wilson , ':,/L 30' Access, Utility, Lac Septic System
DB 1440 PG 501 `'' in Easement (15' each side C/L) ,
Tatat See Easement Call Table
LO
302.a3.
Sugar Valley Trail - - - - - ' Tie Una '�
-- -- - ,RS Cc y
F� rn� Well 112
` 0 D
C/L 40' Access, Utility, &Septic System :3 :-j _6 � ��
LOT 1
E
Easement (20' each side C/L) Z 10
I rye
See Easement Call Table Co j i 1.031 Acres +/-
s� o= . LOT 2
E-13 o n 4°
.n v_
T ? i
- - - - - F g !� Q 1.209 Acres
:17-1
sr
Cn
Gravel Drive 1 - _ Cr.
oto/ CS �Dc
01
C/L 30' Access, Utility, & Septic System
Easement ( each side C/L) r lb cr
See Easem t Call Table - - - �, 24 ^ \° ,�` �h/
E � \ � of 8t;iidincJ
00)c1 o A1>0Ilot 0M };ouse -1 \
IFS$
,r
y lzr�
Ort �8 -
ZG�,ZU
S-4
JE 0 10
1.05'
?.73'
LOT 1 Septic System
Application For: ❑ Site Evaluation/Improvement Permit 0 Authorization To Construct(ATC) ❑ Both
Tyrie of;, plication: ❑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 V� �� Conct Person J' U 6R -N Pa /"k
Billing Address I _,- Phone
City/State/ZIP u/ P_. G O Business Phone 3 3 & 47�5' 3%7
Name on Permit/ATC if Different than Above
Mailing Address
PROPERTY 1NFORMA110N
`Date House/Facility Corners
NOTE: A survey plat or site plan must accompany this application. Included: IR Site Plan ❑Plat(to scale)
(Permit is valid for 60 months with site plan, no a,�P iration with complete plat.)
Owner's Name 13,ti aa r k moil 4� r v,- Phone Number3-3 <v 5 1' 5 ✓?" 9 7/
Owner's Address 7,4!2 ell e rf cF 1 0 CA--, y C' /este/Zip ,'li G Z 7 O G y
Property Address /"tE-1 City
Lot Size Tax PIN# Z d 5- 4, 93 27 3
Subdivision Name(if applicable) Section/Lot#
-''
Directions To Site: %�t wn r� IOPc- uZ=, X --"a
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 a*o
Does the site contain jurisdictional wetlands? ❑Yes Po
Are there any easements or right-of-ways on the site? oyes Biqc
Is the site subject to approval by another public agency? 0Yes
Will wastewater other than domestic sewage be generated? ❑Yes7o
IF RESIDENCE FILL OUT THE BOX BELOW
# People # Bedrooms # Bathrooms Garden Tub/Whirlpool OYes []No
Basement: ❑Yes []No Basement Plumbing: ❑Yes ❑No
IF NON -RESIDENCE FILL OUT THE BOX BELOW r
Type of Facility/Business Total Square Footage of 3 2 0 ` ` # People
# Sinks # Commodes # Showers # Urinals
Estimated Water Usage (gallons per a (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: # Seats
Type system requested: ❑Conventional ❑Accepted ❑Innovative ❑Altemative ❑Other
* Water Supply Type: 0 County/City Water
❑ New Well ❑Existing Well ❑ Community Well
L� Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 11 No
r' 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 pnd rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and
loca ng and flagging pros akinvAe house/fa�i location, roposed well location and the location of any other amenities.
6Site Revisit Charge
Property owner's or owner's legal representat' a si ature
Date(s):
Client Notification Date:
09
?"V1
G ` Davie ounty Health Department
1836 nvironmental Health Section
1 P.D. Box 848
210 Hospital Street'
p U Courier # : 09-40-06
Mocksville, NC 27028
Phone: (336) - 753 - 6780 Fax: (336) - 751 - 8786
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) Replacement Remodeling Reconnection
Name:JAI .-hff' Phone Number f 11/ld�� (Home)
Mailing Addr ss: rwq W(P7��� J�-L �' (Work)
Email
Detailed Directions To
Property Address:
Please Fill In The Following
/I Innformation.About T�hye�E�jXISTING Facility:
Name System Installed Under: A V,'��L'r/t Type Of Facility:
Date System Installed (Month/Date/Year): 1157 - Iq? 7 Number Of Bedrooms: -----'--Number Of People:
Is The Facility Currently Vacant? Yes J0 if Yes, For How Long?
Any.Known Problems? Yes No
If Yes, Explain:.
Please Fill In The F lowing Information About 6%
W Facility: /
Type Of Facility: % ' Aj Z 6 '%nber Of Bedrooms: / umber of People_
Requested By: 4 Date Requested:
ature) .
For Environmental Health Office Use Only
Approved Disapproved
Comments: .
Environmental Health Specialist
Date:__~ -1
*The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee
(extended or limited) that the on-site wastewater system will function properly for any given period of time.
PaYment: Cash Check Money Order #_
Amount:$ Date:
Paid By: Received By:_
Account #: Invoice #:
APPLICANT INFORMATION
Account #
Billed To
Reference Name
Proposed Facility:
It
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
990005528
Sugar Valley Airport
Susan Park
Residence
PROPERTY INFORMATION
Tax PIN/EH #: 5851-26-88434
Subdivision Info:
Location/Address: 249 Gilbert Road -27028 JJ
Property Size: Date Evaluated:
Water Supply: On -Site Well / Community Public
(15
Evaluation By: Auger Boring Pit ✓ P"f Cut
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Structure
C/ E P.
Mineralogy'
y
SOIL WETNESS
RESTRICTIVE HORIZON
,SAPROLITE
CLASSIFICATION
S
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: 1—
LONG-TERM ACCEPTANCE RATE: C . I _T 5
REMARKS: b r �No� P t AS 7 d i Som 1i
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LEGEND
EVALUATION BY: �l c ,
OTHERS) PRESE
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
S
Moic
VFR - Very friable ' FR -Friable FI - Firm VFI - Very firm EFI - Extremely firm
YYe>t
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
lYQtes
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), IJ(unsuitable)
T TAR - T .nna-term arrentanop rano - aal/Aaw/ftp
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