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146 Aviation Way Lot 4v - DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/Pax #(336)753-1680 Account #: 990005528 Billed To: Sugar Valley Airport Reference lame: Proposed Facility: Residential ATO Number: 5118 OPERATION PERMIT Tax PINIEH #: 5851-26-8843-04 Subdivision Info: Sugar Valley Airport Lot # 4 LocationiAddress: Gilbert Road -27028 Property Size: See map **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. C-1System Type: S.T. Manufacturer /�0 Q Tank Date' _ Tank Size (( d Pump Tank Size System Installed By: ; E.H. Specialist: !� a e: GPS Coordinate: M 35 �-V7• o Y5 �Jl% 006'3- Ai. Cf if 3', S r 1 �1 f77� vo 708g3 \� q6O o s C-1%�� Qw�" 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 Tax PIN,EH #. 5851-26-8843-04 Billed To: Sugar Valley Airport Subdivision, Info:- Sugar Valley Airport Lot # 4 Reference Name: LocationiAddress: Gilbert Road -27028 Proposed Facility: Residential PropertyZizo: See map Site Type: 219ew ❑Repair ❑Expansion ATC Number: 5118 **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 --2—L # Bathrooms # People Lf Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats ' Square Footage(or Dimensions of Facility) JV L G � Lot Size 10- -1 )./; Type of Water Supply: ❑County/City E? ell ❑Community Well c, oo System_ Specifications: Design Wastewater Flow (GPD) 1.40 Tank Size lid vGAL. Pump Tank/' pGAL. If it Trench Width 27 G Max. Trenr� Depth 3 ` Rock Depth Linear Ft. 3 40"6f k � n tA y,� Site Modifications/Conditions/Other: �ti �� ��a ah� �i�, 4t -e Contact the Davie County Environmental Healjh Section for final inspection of this system etw 8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760. ` Ile Environmental Health Specialist. DCHD 11/06 (Revised) DO_ ``-•� t�C"t, A ) 30' too? ate: N 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 PIN!EH #: 5851-26-8843-04 Billed To: Sugar Valley Airport Subdivision Info: Sugar Valley Airport Lot # 4 Reference Name: LocationlAddress: Gilbert Road -27028 Proposed Facility: Residential Property Size: See map Site Type: ew ❑Repair ❑Expansion ATC Number: 5118 **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 [T<e11 ❑Community Well �O System Specifications: Design Wastewater Flow (GPD) t9 Tank SizeGAL. Pump Tank/ GAL. It 14 1 Trench Width 3 G Max. Trench Depth Sia Rock Depth Linear Ft. c3 916� , n, ` � ,ded�e7 + Site Modifications/Conditions/Other: As �,.,,stated in 15A Nur Wim * Contact the Davie County Environmental Health Section for final il s 8:30 — 9:30a.m. on the da installation. Tele hon # 1"Ok 4 `'l -'Py n Ueel 4- hceefps C •tis --- Environmental Health Specialiste Date: 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 #: 5851-26-8843-04 Billed To: Sugar Valley Airport Subdivision Info: Sugar Valley Airport Lot # 4 Address: 249 Gilbert Road Location/Address: Gilbert Road -27028 City: Mocksville Property Size: See map 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: R<ew ❑Repair ❑Expansion Permit Valid for: Years ❑No Expiration Residential Specifications: # Bedrooms # Bathrooms e1- # People L4 Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): d, 4 0 Site Modifications/Permit Conditions: Initial Repair Site Plan w S 1� Environmental Health Specialist i.p.11-06 Type of Water Supply: ❑County/City ?Well ❑Community Well As stated in 15A MIA(! 1i)" 5�Q MMA may a LTAR SeP�`c Cl r4c�'e t` Date // - /'�_ —4� 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 PIN.,EH #: 5851-26-8843-04 Billed To: Sugar Valley Airport Subdivision Info: :Sugar Valley Airport Lot # 4 Reverence Name: LocationiAddress: Gilbert Road -27028 Proposed Facility: Residential Propert.y!SiZo: See map Site Type: ew ❑Repair ❑Expansion ATC Number: 5118 **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 ;I- # Bathrooms 'D-- # People 4 Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) r _ ' Lot Size Type of Water Supply: ❑County/City 4[ ell ❑Couuuunity Well System Specifications: Design Wastewater Flow (GPD) 10 Tank Size /) GAL. Pump Tank/ DdCGAL.r 2/ P Trench Width � Max. Trench Depth 3� Rock Dept inear Ft. 3 -1 aoF As stated €n 15A NCP�C 28A.1969(5� of 5-6 ,ed ta.c..� pvl Site Modifications/Conditions/Other: accepted-SyJ to be tvjud is �— C--, Sf -e vin Contact the avie County Environmental Health Section for final inspection of this system 1 b08:30 – 9:30a m_Dn1he day of installation. rmrpi ene.k(336)751-8760. /, 10 — x k kKt.<J d� a Environmental Health SpecialistDate: 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 OPERATION PERMIT Account #: 990005528 Billed To: Sugar Valley Airport Reference Name: Proposed Facility: Residential ATC Number: 5118 Tax PINiEH #: 5851-26-8843-04 Subdivision info: Sugar Valley Airport Lot # 4 LocationiAddress: Gilbert Road -27028 Property Size: See map **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 WAIS 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 #: 5851-26-8843-04 Billed To: Sugar Valley Airport Subdivision Info: Sugar Valley Airport Lot # 4 Address: 249 Gilbert Road Location/Address: Gilbert Road -27028 City: Mocksville Property Size: See map 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: R ew ❑Repair ❑Expansion Permit Valid for: C3'5 -Years ❑No Expiration Residential Specifications: # Bedrooms # Bathrooms )L— # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People _# Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): aWo Type of Water Supply: ❑County/City ifWell ❑Community Well As stated in 15A NCAC 18A.1969(5) Site Modifications/Permit Conditions: ash-Itted Systems rray also he usedd Site Plan System Type LTAR`` Initial C • 7 (5) CA <Ze air o1 o.t75— Do rl 1 ,.1 do - Environmental Health Specialist Date­tO�,:71-6 / (J i.p. 11-06 Applifatiorrkr: V 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 CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed V f47/' r—Contact Person Billing Address Z Home Phone q'� City/State/ZIP 2 hone 3 v (P 7Z Z - Name on Permit/ATC if Different than Above al I Mailing Address _ City/State/Zip PROPERTY INFORMATION 'T-'( `-r)/ *Date NOTE: A survey plat or site plan must acbampf4 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 g� `5 71 Owner's Address ' U J 0 City/State/Zip - o N 0 -- Property Address t City Z7 ®� Lot Size Tax PIN# Subdivision Name(if applicable)ection/L_ot# Directions To Site: u✓.�nc) 9� i sic Zr-o - ; E 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 9No Does the site contain jurisdictional wetlands? ❑Yes Edo Are there any easements or right-of-ways on the site? ❑Yes Elo Is the site subject to approval by another public agency? ❑Yes ErNo Will wastewater other than domestic sewage be generated? ❑Yes 2<0 IF RESMENCE FTLL OUT THE BOX BELOW # People # Bedrooms # Bathrooms I Garden Tub/Whirlpool ❑Yes [iso Basement: ❑Yes o Basement Plumbing: ❑Yes ®3153� TF NON-REgMENCE 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: Vonventional ❑Accepted ❑Innovative []Alternative ❑Other. Water Supply Type: ❑ County/City Water VNew 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? PTo 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 locat g and flagging or Prig the ouse/facility location, proposed well location and the location of any other amenities. Site Revisit Charge P operty owner's or owner's legal representative signature Date(s): Client Notification Date: ' DAVIE COUNTY HEALTH DEPARTMENT • ' ' • Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990005528 Tax PIN/EH #: 5851-26-8843-04 Billed To: Sugar Valley Airport Subdivision Info: Sugar Valley Airport Lot # 4 Reference Name: Location/Address: Gilbert Road -27028 Proposed Facility: Residential Property Size: See map Date Evaluated: G - _,.)Z ,Lt —J -()- Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit�� Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position l_. I_ Slope % HORIZON I DEPTH - -7 p - Texture group S C. L.. G Consistence 5SS l 5 Structure 0, 56r k Mineralogy HORIZON II DEPTH % - 3 Texture group Sc- Gw5G1.� Consistence J Structure bL3bt- X C Mineralo 17 HORIZON III DEPTH 0. - V7 Texture groupL S Consistence , r Structure 39k. CL 4 R Cly 5 Mineralogy HORIZON IV DEPTH - y`3 417:--& re Texture groupL, Consistence Structure C-7:5 C Mineralogy P n SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION PS LONG-TERM ACCEPTANCE RATE . / 5 7 SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: C� REMARKS: LEGEND EVALUATION BY: �� �}J � C C) ^ S OTHER(S) PRESENT: ��5 ct ✓1 loci, '. 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 . Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm YYgt 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 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) T TAR - T nnn_tP. orrn..to.`-