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245 Gilbert Road Lot 2} t' r'cat�on For: ,VSite Evaluation/Improvement Permit 1' W- ApplicEktidn: ❑New System ❑Repair to Existing CA « JxEwc ❑ Both Ve IM fFr aEo> ifKati isting System or Facility ***IMPORTANT*** THIS APPLICATION CANNOTBE 11 SSED UNLESS ALL REQUIRED INFORMATION IS PROVIDED. Refer to the INFO 1 BUItli iTIN for i7ptiC><ucti APPLICANT INFORMATION Name to be Billed Billing Address " City/State/ZIP, 6e Name on Permit/ATC if Different than Above. Mailing Address PROPERTY INFORMA' NWIRUiuirioI ItAL ncr%un �� Vak,L IE NTY �I 4� Home Phone If-P4 I w C% -// 43trsimn Phone ?`ZZ �!�R.2-- Cry/ *Date House/Facility Comers Flagged 64-10 NOTE: A survey plat or site plan mdsf accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is yalid for 60 nj)ths with site plan o expiration 'th complete plat.) Owner's Name Phone Number 5--7 Owner's Address City/State/ZipJ�,A-P- Property Address City Z -_7 $ Lot Size Tax PIN# Arl - Z6- 04; . Z Subdivision Name(if applicable) Section/Lot# Directions To Site.77ff7 {-� eve f -rt ; 0 I U If the answer to any of tile' followi/g questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes''9N6-_ Does the site contain jurisdictional wetlands? Dyes Are there any easements or right-of-ways on the site? ❑Yes 6 N'o Is the site subject to approval by another public agency? ❑Yes ZW6 Will wastewater other than domestic sewage be generated? Dyes IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms �_ # Bathrooms Garden Tub/Whirlpool Dyes �d4o Basement: ❑Yes EPKo Basement Plumbing: ❑Yes 2Ncr-.. 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: ❑Accepted ❑Innovative []Alternative ❑Other. Water Supply Type: ❑ County/City Water Xew 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? /No This is to certifythat 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 locat and flagging o king tlhouse/facility location, proposed well location and the location of any other amenities. rot owner's or owner's legal representative signature Site Revisit Charge Date(s): Art* rrze 4 73 °fib Client Notification Date: VLA\ R/W Monument `4jjAo rt Run �a y / C 'ai� o I° 14 Ars Building `J Y ryf N DB 144—PG 1484.11' X Q\�)r 5 �E y DB 144—PG 1484.11' APPLICANT INFORMATION DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation Account #: 990005528 Billed To: Sugar Valley Airport Reference Name: Susan Park Proposed Facility: Residence PROPERTY INFORMATION Tax PIN/EH #: 5851-26-8843. Subdivision Info: Location/Address: 249 Gilbert Road -27028 I� Property Size: Date Evaluated: Water Supply: On -Site Well / Community Evaluation By: Auger Boring 1-� Pit V & Public Cut FACTORS 1 �� / ; ` ,' 6 7 Landscape position Slope % 1 HORIZON I DEPTH 6-:2 Y - C C' -- Texture group ,¢ G% 4. 5C4 5Gc- 5G4. 5C X i -o ' F Consistence Qlaj S1 t ,e S PSS f g I,(' - Structure a ,V �ShO�* s►3,C �`P e rpt Mineralogy •- HORIZON II DEPTH Z ta `' , to- / - :3gp Texture group Crsa Consistence i je Ow UPOstAr, w J5 J i! fir Structure M as Td t ael.5 rho*., JJf 0*5 %Jt Mineralogy HORIZON III DEPTH -y- P r. ! t vto -43 OWT ; Texture group 60c It L Consistence r.• r Structure 8 /o'-4 Mineralogy ,cJ HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON �' I '• ` SAPROLITE i `•X a 344 CLASSIFICATION L(, it lil li LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: a ��) LONG-TERM ACCEPTANCE RATE: REMARKS: � k6 c Q r4• EVALUATION BY: OTHERS) USE 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 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 NDIM 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) TTAR - T.nno-term Arr,-ntnnre rat,- - oaUiau/ft) ncinc r 1 1. k 1, George Robert Sionti, Certify that this plot was drawn under ift 4 George Robert Starse. Pr� Liand Survoinsr. L-3182. cor" lat a," Filed for registration of c I ock S:cgrPIrvislon from an actual survey made under iny supervision (deed description of the following as Indicated thusi. o fed in Book Page itic.) (other): that the boundaries not 1 0 or Ea,: Gilbert Road S.R. 1437 surveyed are clearly indicated as drawn front infitrina tion found in Book 0. That thile Plot in of a isurvey Owt c a subdivision of land wilthin P 62 0 -_;.that the ratio of precision as calculotild is 1/10.000: that this 0 the area of a county or riverticipalfly that how an ordiviance that FEBRUARY 23 20 H and recorded V prepared in accordance with G.S. 47-30 as arriended. Witnoss "I original requictes paroole of larid; 60' Public R/W 20'+/- Pavement CK :09holluro. rogistrat ion nufter and seat qf,) r-; �? . 5 -, is RB 824 0 PG 319 b. That this plot Is of a survey that In loodited in mxh portion of a in Plot Book P age -A I * 13 October A. D. 2010 0 o: this day a * RB 843 0 PG 785 county or triviticipolity Ithat in unregulated an to an ordinance AL Brant Shoot, Register of Goods a PB 10 0 PG 268 11hat rogulotee porcole of land; Pinobrook Or in Sea I or Storrip George R. Stone s PB 10 0 PG 275 C� That this plot in of a survey of an eidirting porcei or parcels Filing Fe Paid t -/k-/ SIR 1437 v Gilbert Rd I I I ng Fie paid ' ' ' El SR 1437 d. That the plat is of a survey of another category, such as the recorriblivation of existirsill porcele, a court-wdered survey or other Of kind; C Surveyor so L 3162 Is 1-1i B / f - DEP T1- a Registration Nuffilber eirception to the definition of subdivision; Di V -SS CALL TABLE FOR CENTER LINE OF . 4z ACCESS & UTILITY EASEMENT El o. That the inforyntation - -11-11 to this surveyor is such that I arm SEAL uniable to mks a determination to Use bW of try Plot Revisions: <2-2 -2011 L-3162 ability as to provisione contalined in (a) through (d) COURSE BEARING DISTANCE 1. Septic System Easement Revisions 0 .7 2. Well Easement Additions E-1 S 84043'49"E 40.89' Tie Line George R. Stone. PLS Su 17N E-2 N 41 *42'29"E 120.18' Professional Land 94tvya, L-3162 E-3 N 41*42'29"E 100.05' E-4 N W23'40"E 76.62' Vicinity Map (Not to Scale) Exempt Minor Subdivision E-5 N 72022'06"E 119.09, STATE OF NORTH CAROLINA E-6 S 85009'08"E 126.14' Tie Line COUNTY OF DAVIE E-7 S 14000'38'V 30.16' Tie Line E-8 N 1 VOO'38"E 30.16' rie Line E-9 S 85002'56"E 28.34' 1. Andrew Meodwefl, Review Officer of Davie County E-10 N 30057'0 1 "E 206.58' certify that the map or plot to which this certification E-1 1 S 85002'56"E 21.36: is affixtild meets all statutory requirements for recording. E-12 S 23028'50"W 155.56 Review Officer. 01-4- Beoring 0�ritentatjon E-13 S 02015'24"W 88.38, 19 PHASE H LOTS 3 & 4 E-14 S 16034'1 4"E 252.59' PROPERTY LINE CALL TABLE Date; a PG 3 E-15 S 04*04*1" 176.36' 7, 1 1 k 3 1 Z - I / REI 824 0 PIS 319 COURSE BEARING DWAWE "NO APPROVAL REOUIRED BY THE CO NING DEPARTMENT" L-1 S 85055'41 "E 224.90: &101<- Tax Lot 3.01 L-2 S 04004'19'V 180.00 Planning Director Tax Map E-6 L-3 S 04*04'1 9"W 180.00, n/f Deritieti S. Stanley L-4 -N 45*55'41'V 224.94' D,#e & Mary Beth Stanley L-5 N 04004'38"E 180.00, Tax Lot 4.03 DB 170 0 PG 236 L-6 N 04004'38"E 180.00: L-7 N 85055'41 "W 224.92 Tax Map E-6 Tax Lot 4.04 n/f Wayne M. Herritphill Tax Map E-6 cl 11 DB 146 0 PG 771 n/f Denise Cynthia Wilson C/L 30' Access & Utility Easement DB 144 0 PG 501 Easement (15' each side C/L) T-Bor vi Fnd I io See Easement Coll Table TIE LINE CALL TABLE -E-I Sugar Valley Trail COURSE SWING DISTANCE T-4 IRS L-,5 IRS L-6 IRS - N A T-3 1/2" EIR Fnd T-1 S 27*1 1'56"W 26.35' (not to scale) T-2 S 83045'05"E 60.17' T-3 S 04004'38"W 454.79' C/L 40' Access, Utility, & Septic System LOT 1 T-4 N 04004'38"E 669.22' F EasAyient (21p' each side C/L) z Tax Lot 3.03 0 Phase I Tax Map E-6 Sea Easement Coll Table z 0 To x Lot 4.05 n/f Stephen L. Leighton LOT 4 �1: W� W2 az Ix & Deborah G. Leighton CIL -6 LOT 3 LOT 2 r Tax Map E E-13 JF g RB 832 0 PG 83 0.929 AlleS F d Tax Lot 4.06 W Tax Mop E-6 WELL EASEMENT FOR LOT 3 CALL TABLE 0 1,j 0.929 Acres 9 Well Easement Gravel Drive fair LOT 3 W_ Well Easement COURSE BEARING DISTANCE See Call Table - for LOT I .0- 1,J 20.00' See Phase I Plot L-3 Total E-15 W-1 N 85055'4 11"W 40.00' 73 63' 116 86.37' 20.00' -L-2 Total W-2 N 040041 9"E 20.00' IRS CC S-1 IR�'CC 88.3Y 91.67' 01 C/L 30' AA+ty Ease. ie, t Easement each side C/L) S-2 2o -S See Eastern Call To%=1 -Ijilic tern rnent F (10. each - Side, vall" S-4 �_of C/L) Tax Lot 4 CALL TABLE FOR Tax Map E-6 n/f Human Service Alliance, Inc. RB 824 0 PG 319 St/W - RWA-f-WaY LEGEND FC - Foos of Curb EIP - Existing iron Pipe BoC Back of Curb EIR - Existing Iron Rebor PP Power Palo P - Post LP - Light Palo CM - Concrete Monument MH - Man Hole IRS - Iron Robor Set CH - Chord Distance P/L - Property Line P/O - Part of C4A - Controlled Access D8 - Deed Book - Concrete Pipe PB - Plot Book CMP Corrugated Metal Pipe RB - Record Book CPP PG - Page -F- 1��Pdfa=dipe CID - Catch Basin -0- Overhead 1.1tifitiest -S- Solver Line -X- FInce WM - Water Motor Fnd - F=d WV - Water Volive n/f - Now or Formerly Bill - Bench Mark Will, - Nortimenumeryted Point Center Line TBM - Tz" RRS - ax Bench Mork Spike EP - Edge of Pavement CTV - Cable Television Pedesto TP - Telephone PwIesta ETS - Find Tamsfaryiner So) -w- Water Une CO - Sanitary Sewer Clean Out X - NMP (Nonmonumented Point) S-12 'R/W MON - Concrete R/W Monument 143.53' IRS CC - 1/2" Rebar Set Control Monument 100 0 100 200 C40PHIC SCALE -_fEET I (we) hereby certify that I am (we are) the owner(s) of the proplerty dewribdid hereon, which is located in the subidivision Nnsidliction of Davis County and #Kit I hereby adopt Oils subdiviligon plan with my free consent. established mirtimum buillding setback Knee and dodkx*9 all streetat aftys. waft. parks and other Wtft and easernents to public or pdvats use as noted. 300 �2-2 2- // fAJ. aele�e OA Deb ON -Ke) bob OW-(*) Nile Grove' Road House LOT 4 Septic Easement S" Coil Tcbfe\,� �_ �10 Tax Lot4 L07- 3 Septic LOT 2 Sept Tax Map E-6 S-5 Easement n/f Human Service Alliance, Inc. ic So. C.,, en, Table See Phase I Plot RB 824 0 PG 319 AN -12 Fie Revised Survey for: Sugar Valley Airport 100 YEAR FLOOD HAZARD ZONE (AE) REFERENCE "FIRM" (FLOOD INSURANCE RATE MAP) Phase II MAP NUMBER: 3710584000J PANEL- 5840. DATE: 9-17-2008 LOT 3 & Lot 4 BFE: 722.00' NAVD 88 Tax Lot 4.07 & Tax Lot 4.08 Tax Map E-6 Record Book 824 0 Page 319 Plot Book 10 0 Page 275 OWNER: IF W. Thomas White for: Hurnon Service Alliance 3983 H.S_k Circle Winston-Salem, N.C. 27101 LOT 3 Acreage: 0.929 Acre: NOTES.- LOT 4 Acreage: 0.929 Acre I * apr�ww*-20 Total LOTS 3 & 4 Acreage: 1,858 Acres 2. MWwri-wn bAdIng Setback Lines: All Area Computations by Coorv$inote Geometry -F"g* We Phiar- W, Side. 15' SCALE TOWNSIW COUNTY STATE WX 3. VatereW Ckwelfication: None 1 100' Farmington Davie North Carolina 110-13-200 4. No bS= br N=- Momrnents Company Ston.e Land Surveying 5. Nt, 410iii0ii'dWtono" am rraostuirsid SUM&YM. 111linkidin Firm *AY*W. C-wI704 JIM 10. -*W0w** VOWW diekwic". [*,WT A 76HIM - M pr9poillisid'hNn" shW be caratructed MWpM Gm%o ftbo ftr^ nX L-310 MW W wim 04 low fiftr bsiF4 a ""Umm of 113 Drum Lane (3M) 998-4733 7511OR2 GIRS Modkiliville, 111I.C. '27028 2" abon,ft SIFE (722' NAVO 88). S� X� PHASE 11 / LOTS 3 & 4 'r-P"C SYSTEM EASEMENT AREAS 6L BEARING DISTANCE S-1 S 85055'41 "E 14.01 S-2 N 15*28'27"E 198.62' S-3 S 85*55'41 "E 53.28' S-4 N 15028'27"E 510.00' S-5 N 16959"54"IE 101.31' S-6 S 18059'54"W 100.79' S-7 N 86034'36"W 115.91, S-8 N 12002'20"E 55.25' S-9 N 88058*53"E 116.27' S-10 N 14*30-ME 143.51' S-11 S 75031'06"E 49.46' S-12 S 14030'29"W 143.53' S-13 N 75029'31 "W 49.46' I (we) hereby certify that I am (we are) the owner(s) of the proplerty dewribdid hereon, which is located in the subidivision Nnsidliction of Davis County and #Kit I hereby adopt Oils subdiviligon plan with my free consent. established mirtimum buillding setback Knee and dodkx*9 all streetat aftys. waft. parks and other Wtft and easernents to public or pdvats use as noted. 300 �2-2 2- // fAJ. aele�e OA Deb ON -Ke) bob OW-(*) Nile Grove' Road House LOT 4 Septic Easement S" Coil Tcbfe\,� �_ �10 Tax Lot4 L07- 3 Septic LOT 2 Sept Tax Map E-6 S-5 Easement n/f Human Service Alliance, Inc. ic So. C.,, en, Table See Phase I Plot RB 824 0 PG 319 AN -12 Fie Revised Survey for: Sugar Valley Airport 100 YEAR FLOOD HAZARD ZONE (AE) REFERENCE "FIRM" (FLOOD INSURANCE RATE MAP) Phase II MAP NUMBER: 3710584000J PANEL- 5840. DATE: 9-17-2008 LOT 3 & Lot 4 BFE: 722.00' NAVD 88 Tax Lot 4.07 & Tax Lot 4.08 Tax Map E-6 Record Book 824 0 Page 319 Plot Book 10 0 Page 275 OWNER: IF W. Thomas White for: Hurnon Service Alliance 3983 H.S_k Circle Winston-Salem, N.C. 27101 LOT 3 Acreage: 0.929 Acre: NOTES.- LOT 4 Acreage: 0.929 Acre I * apr�ww*-20 Total LOTS 3 & 4 Acreage: 1,858 Acres 2. MWwri-wn bAdIng Setback Lines: All Area Computations by Coorv$inote Geometry -F"g* We Phiar- W, Side. 15' SCALE TOWNSIW COUNTY STATE WX 3. VatereW Ckwelfication: None 1 100' Farmington Davie North Carolina 110-13-200 4. No bS= br N=- Momrnents Company Ston.e Land Surveying 5. Nt, 410iii0ii'dWtono" am rraostuirsid SUM&YM. 111linkidin Firm *AY*W. C-wI704 JIM 10. -*W0w** VOWW diekwic". [*,WT A 76HIM - M pr9poillisid'hNn" shW be caratructed MWpM Gm%o ftbo ftr^ nX L-310 MW W wim 04 low fiftr bsiF4 a ""Umm of 113 Drum Lane (3M) 998-4733 7511OR2 GIRS Modkiliville, 111I.C. '27028 2" abon,ft SIFE (722' NAVO 88). S� X� 1, SearMeebart Stan*, certify that this plot was drawn under uer ss►are'il10 from en salve{ wroey ar0a enNr sy suporvieloa (dead description effe In sect l�. Pass ate. ) ( other ): that the bov"der les not w'vitsO are clearly Indicated as draw* from infersnstion found In Book , tap __.4 .,L that the retie N precision as calculated is 1/10,000: that this plot ooe or"ared in accerdence with O.S. 47-30 as attended. Witness try original ♦ •,r'.•• 'gmstra"an nuaeer and Goal a RB 824 O PG 319 net l e _ 44P.01 ober A. 0. 2010 ._ • R8 843 O PG 785 • PB 10 O PG 268 s•• t s rGP George R. Stone is PS 10 O PG 275 surveyor L 3162 ;�F•�'4 "Y Registration Number $EAL Plot Revisions: 2-2 -2011 0 L -3162Q 2 1. Septic Easement Revisions n 2. Well Easement Additions h'0 BER STATE OF NORM CAROLINA COIfMY OF DAW 1,-Mdrew MsaAwt, taview Officer of Davie County. cerWy that tilmap or plat to which this e�ific ltation b Ines �1 requirements Ift recording. Review Offloer: Date; V IL ..NO REQUIRED UY THE COUNTY PUNNING DEPARTMENT' At Plann ng Director Dot Tax Lot 4.03 Tax Map E-6 n/f Wayne M. Hemphill DB 146 O PG 771 L George Robert Stara. Vrofe sherial Land Surveyor. L-3162. cortMy to one of the gas d�® or �-. Gilbert Roal El is- of _ E-1 S 84°43'49"E 40.89' the ones u� county or "nunicipeffb' that las on ordinate that , 60 Public R/W 2( E-3 , „per of kind,. 100.05' E-4 N 50023'40"E b. That this plat in of a survey that is located In ouch portion of a E-5 N 72°22'06"E 119.09' aouitq or irnsllelitaft Out in unregulated as to an ordinance S 85°09'08"E 126.14' E-7 that regulates It- , ' of land: 30.16' E-8 N 14000'38"E 30.16' E-9 S 85002'56"E 28.34' C. That this plat Is of a survey of an •rioting parcel or parrots N 30°57'01 "E 206.58' E-11 of i tick 21.36' ' Od. That thio plat 4 of a smxvey of onottw category, such as the E-13 I 88.38' iwolinWeation of s loft poreals, a court-ordered survey or other S 16034'1 4"E 252.59' E-15 exupum to the defhlRion of sibdlvioion: 176.36' T-1 a. That ft Information available to this surveyor is such that I am N 12'46'1 9"E 122.58' T-2 unable to nab a deMmrMatbn to the best of my professional S 76°54'49"E 6.99' T- abft we to provisbra owitlained in (a) (d) above. S 12°46' 19"W 254.10' T-4 George R. Stone, PLS S 06"17'20"W 178.72' It of tonal L-3162 e Exempt Minor Subdivision ' Bearing Orientation I PG 319 I RB 824 O I Tax Lot 4.04 Tax Map E-6 U_ n/f Denise Cynthia Wilson I T DB 144 O PG 501 W I S.R. 1437 Pavement X i I CALL TABLE FOR CENTER LINE OF ACCESS do UTIUTY EASEMENT COURSE BEARING DISTANCE E-1 S 84°43'49"E 40.89' E-2 N 41.42'29"E 120.18' E-3 N 41"42'29"E 100.05' E-4 N 50023'40"E 76.62' E-5 N 72°22'06"E 119.09' E-6 S 85°09'08"E 126.14' E-7 S 14000'38"W 30.16' E-8 N 14000'38"E 30.16' E-9 S 85002'56"E 28.34' E-10 N 30°57'01 "E 206.58' E-11 S 85002'56"E 21.36' E-12 S 23°28'50"W 155.56' E-13 S 02°15'24"W 88.38' E-14 S 16034'1 4"E 252.59' E-15 S 04004"1 9 "W 176.36' Tax Lot 3.01 Tax Map E-6 n/f Daniel S. Stanley do Mary Beth Stanley DB 170 O PG 236 C/L 30' Access & Utility Easement ' Easement (15' each side C/L) 60 r Total See Easement Call Table 102.83' Sugar Valley Trail E-1 IRS CC Tie Line L- ---- - IRSC Filed for registration at 1V l� - o'clock M 20� and recorded o �h K U O r ^ u i r V) �L, a a a M. Brent Shoot, Register of Deeds o s Es V Pinebrnok Dr in FII I Fee Paid 111- Cr SR 14,57 a Gilbert Rd C of SR ', 437 ri (T U 41 tV \ F v O DEPUTY --- -------------- rr vi N s l� co Well L-2 i \ o C/L 40' Access, Utility, do Septic System J � j�E--6' LOT 1 F F f Easement (20' each side C/L) o r- `' Tie Line \ � I LOT 4 ( See Easement Call Table � aD i Z a F\ 1.031 Acres Tax Lot 4 Phase 11 LOT 3 W w o e 3 �° LOT 2 ----� I Ino t° 0 ` 1 1 Tax Map E-8 E-13 .J n f Human Service Alliance, Inc. I Tax Lot 4.08 Phose II _ - - - - - F_9 - o, o F° . f 1.209 Acres + / B 824 O PG 319 Tax Map E-6 Tax Lot 4.07 ��/ - -- --�:\ `E'�? f�7' ell o W }o� n _� c' o\ F�„ �o Tax Map E-6 /✓�'�/ Gravel Drive \ _ _ - ` S 4 N I J o Well Easement I �4 '? a ` ` `� Well Easement I ` ` for LOT 1 for LOT 3 _ _� � \ \\ ~' iC�B 02� ` � See Call Table See Phase II Plat 5 '/ ' C� 10�` ` \ oto/ 1`� \¢c� i � � T- C/L 30' Access do Utility Easement nevemer Easement (15 each side C/L) 111; e ¢0c owo� See Easemen all Table \ ' --- �o'-o\ \tt p _20' Se _- F House J 1 ;y ` r Building PLIC `` S�°m Eos _� tt I LOT 4 nP 1\ �r Z-! ry ent (S; Septic IRS Su a7'Vail, Phas@ 1 Easement Plot) ��_ See Phase II Plat 1-6IRS I Ort Runty _ _ LOT 3 - I CALL TABLE FOR �, a� Septic Easement 5-10 SepticOEa Easement PHASE I / LOTS 1 oft 2 __ '�-- See Phase II Plat rn _ r r. '"C SYSTEM EASEMENT AREAS --�_ � l � � �_ � See Call Table j Aft NI Vicinity Map (Not to Scale) PROPERTY LINE CALL TABLE PHASE i / LOTS 1 & 2 COURSE BEARING DISTANCE L-1 P/0 - Part of N 12°46'19"E 249.37' L-2 PB - Plat Book N 12046'1 9"E 116.32' L-3 PG - Page S 76054'49"E 141.90' L-4 -S- Sewer Line S 24033'31 "E 128.65' L-5 Wv - Water Valve S 46002'34"E 174.53' L-6 TBM - Temp°rory Bench Monte S 15°51'03"W 100.00' L-7 CTV - Coble Television Pedestal N 74008'57"W 96.71' L-8 Co - Sanitary Sewer Clean Out S 30°19'10"W 61.04' L-9 N 81040'54"W 249.62' L--10 S 51029'49"E 233.49' L-11 S 26°11'10"E 90.55' TIE LINE CALL TABLE COURSE BEARING DISTANCE. T-1 N 12'46'1 9"E 122.58' T-2 S 76°54'49"E 6.99' T- 3 S 12°46' 19"W 254.10' T-4 S 06"17'20"W 178.72' Boulder Tie J_;ti Painted ^X nee on, 1&112. Fill Fnd m� Tax Lot 3.03 i Tax Map E-6 / J n/f Stephen L. Leighton do Deborah G. Leighton RB 832 O PG 83 WELL EASEMENT FOR LOT 1 CALL TABLE 3/4" EIP Fnd 3/4" EIP Fnd CO RCE BEARING DISTANCE - T-4 U W-1 N 58053'59"E 49.27' W-2 S 33°43'23"E 62.22' W-3 S 72°03'13"W 32.62' Tax Lot 4 Tax Map E-6 n/f Human Service Alliance, Inc. RB 824 O PG 319 -� -- COURSE BEARING DISTANCE - -- -- S-1 S 41042'29"W 118.58' - S-2 S 85°02'56"E 107.24' S-3 S 85002'56"E 21.43' S-4 N 30057'01 "E 99.08' F S-5 N 41005'30"E 52.41' S-6 N 23047'07"E 84.24'-- LFGENc S-7 S 84029' 11 "E 106 02' _ R/W RSght-of-Way FC - Face of Curb EIP - Existing Iron Pipe BoC - Back of Curb S-8 S 14°25'36"W 229.96' EIR - Existing 1Mn Rebar PP - Power Pole S-9 N 75031'06"W 49.46' P - Post LP - Light Pole CM - Concrete Monument MH - Mon Hob S-10 N 14030'29"E 55.57' 100 YEAR FLOOD HAZARD ZONE (AE) VS - "" Rebar set CH - Chord Distance S-11 N 75031'06"W 43.27' REFERENCE "FIRM" (FLOOD INSURANCE RATE MAP) O/L - c-, up" Line P/0 - Part of /A - CoMroded Access DB - Deed Book 9 - Coas*ete Pipe PB - Plat Book Mr - Corrugated Metal Pipe RB - Record Book CVP _ Corrugated Ptdstic Pipe PG - Page -F- 100 Year Flood Boundary CB - Catch Basin -0- Overhead Utilities -S- Sewer Line -X- Fence WM - wotar Meter Fnd -Found Wv - Water Valve n/f - Now or Fornedy BM - Bench Mark NhIP - Nonmonurnented Point TBM - Temp°rory Bench Monte CL - Center Line RRS - RaA Road Spike EP - Edge of Pavement CTV - Coble Television Pedestal TP - Telephone Pedestal ETB - Electric Transformer Box -W- water Lina Co - Sanitary Sewer Clean Out X - NMP (Nonmonumented Point) R/W MON - Concrete R/W Monument IRS CC - 1/2" Rebar Set Control Monument 100 0 100 200 300 GRAPHIC SCALE - FEET Revised Survey for: Sugar Valley Airport Phase I MAP NUMBER: 3710584000) LOT 1 &Lot 2 PANEL: 5840, DATE: 9-17-2008 Tax Lot 4.05 & Tax Lo! 4.06 BFE: 722.00' NAVD 88 lax Map E. -6 Record Book 824 ® Page 319 Record Book 843 0 Page 795 I (we) hereby certify that I am (we are) the owner(s) F Plat Book 10 ® Page 268 of the property described hereon, which is located in OWNER: �----F W. Thomas White for: LOT 1 Acreage: 1.031 Acres the subdivision jurisdiction of Davie County and that NOTES: LOT 2 Acreage: 1.209 Acres +/ - I this fHarmon Service Alliance t1°r°� adopt subdivision plan with my 3983 H.SA Circle 1. Zoning: R-20 Total LOTS 1 & 2 Acreage: 2.240 Acres +/ - consent, established minimum building setback lines Winston-Salem, N.C. 27101 2. Minimum Building Setback Lines: All Area Computations by Coordinate Geometry and dedicate all streets, alleys, walks, parks and Front: 30', Rear: 30', Side: 15' SCALE TOWNSHIP COUNTY STATE DATE other sites and easements to public or private use 3. Watershed Classification: None 1" = 100' Farmington Davie North Carolina 10- 13-2010 an noted. 4. 4. No USGS or NCGS Monuments 2 22- ,>, tt% found within 2000' of site. Stone Land Surveying Company 5. All shown distances are measured SURVEYED: Business Fpm, Certificate Number. C-1704 JOB NO. B''' 0) horizontal ground distances. DB,MT George Robert Stone, PLS Number. C-1 7610 No. 6. Allrohomes shall be constructed with the lowest floor being a minimum of MAPPED: 3 I ru- i on- ; 3.5 1 1 .' S 766 O R1 GRS bob omm.(s) 2' above the BFE (722' NAVD 88). M,r.kvo ll:. ti L i DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P.O. Bos 848/210 Hospital Street Courier 909-40-06 Mocksville, NC 27028 Phone#: (336) 75.3-6750 Fax#: (336) 751-8786 July 27, 2010 Sugar Valley Airport 249 Gilbert Road Mocksville, NC 27028 Attention: Susan Park Re: Site Evaluation Tax PIN: 5851-26-8843-2 Dear Mrs. Park: As requested, Robert M. Nations, REHS; Environmental Health Specialist with this office on June 21, 2010, evaluated the above -referenced property at the site designated on the plattsite plan that accompanied your improvement permit application. The evaluation was done in accordance with the laws and rules governing wastewater systems in North Carolina General Statute 13 OA - 333 and related statutes and Title 15A, Subchapter 18A, of the North Carolina Administrative Code, Rule .1900 and related rules. Based on the criteria set out in 15A, Subchapter 18A, of the North Carolina Administrative Code, Rules .1940 through .1948, the evaluation indicated that the site is UNSUITABLE for a ground absorption sewage system. Therefore, your request for an improvement permit is DENIED. A copy of the site evaluation is enclosed. The site is unsuitable based on the following: Rule .1941 Soil Characteristics Rule .1942 Soil Wetness Rule .1943 Soil Depth These severe soil or site limitations could cause premature system failure, leading to the discharge of untreated sewage on the ground surface, in surface waters, directly into ground water or inside your structure. The site evaluation included consideration of possible site modifications, and modified, innovative or alternative systems. However, this office has determined that none of the above options will overcome the severe conditions on this site. A possible option might be a system designed to dispose of sewage to another area of suitable soil or off-site to additional property. For the reasons set out above, the property is currently classified UNSUITABLE, and an improvement permit shall not be issued for this site in accordance with Rule .1948(c). However, the site classified as UNSUITABLE may be reclassified as PROVIONALLY SUITABLE if written documentation is provided that meets the requirements of Rule .1948(d). A copy of this rule is enclosed. You may hire a consultant to assist you if you wish to try to develop a plan under which your site could be reclassified as PROVISIONALLY SUITABLE. You have a right to an informal review of this decision. You may request an informal review by the environmental health supervisor with this office. You may also request an informal review by the N.C. Department of Environment and Natural Resources regional soil specialist. A request for informal review must be made in writing to the Davie County Health Department, Environmental Health Section. You also have a right to a formal appeal of this decision. To pursue a formal appeal, you must file a petition for a contested case hearing with the Office of Administrative Hearings, 6714 Mail Center, Raleigh, N.C. 27699-6714. To get a copy of a petition form, you may write the Office of Administrative Hearings or call the office at (919) 733-0926 or from the OAH web site at www.ncoah.com/forms.shtml. The petition for a contested case hearing must be filed in accordance with the provision of North Carolina General Statutes 130A-24 and 150-B-23 and all other applicable provisions of Chapter 150B. N.C. General Statute 130A-335 (g) provides that your hearing would be held in the county where your property is located. Please note: If you wish to pursue a formal appeal, you must file the petition form with the Office of Administrative Hearings WITHIN 30 DAYS OF THE DATE OF THIS LETTER. The date of this letter is July 27, 2009. Meeting the 30 day deadline is critical to your right to a formal appeal. Beginning a formal appeal within 30 days will not interfere with any informal review that you might request. Do not wait for the outcome of any informal review if you wish to file a formal appeal. If you file a petition for a contested case hearing with the Office of Administrative Hearings, you are required by law (N.C. General Statute 15011-23) to send a copy of your petition to the North Carolina Department of Environment and Natural Resources. Send the copy to: Office of General Counsel, N.C. Department of Environment and Natural Resources, 1601 Mail Service Center, Raleigh, N.C. 27699-1601. Do NOT send the copy of the petition to Davie County Health Department. Sending a copy of your petition to Davie County Health Department will NOT satisfy the legal requirements in N.C. General Statute 150B-23 that you send a copy to the Office of General Counsel, NCDENR. Please call or write this office if you have any questions or need any additional assistance, as follows: Telephone number: (336) 753-6750 Davie County Health Department Environmental Health Section P.O. Box 848 Mocksville, NC 27028 Robert M. Nations, REHS Environmental Health Specialist /df Enclosure(s): Soil -Site Report Rule .1948 Invoice LAWS AND RULES FOR SEWAGE TREATMENT AND DISPOSAL SYSTEMS 15A NCAC 18A.1900 Rule .1948 .1948 SITE CLASSIFICATION (a) Sites classified as SUITABLE may be utilized for a ground absorption sewage treatment and disposal system consistent with these Rules. A suitable classification generally indicates soil and site conditions favorable for the operation of a ground absorption sewage treatment and disposal system or have slight limitations that are readily overcome by proper design and installation. (b) Sites classified as PROVISIONALLY SUITABLE may be utilized for a ground absorption sewage treatment and disposal system consistent with these Rules but have moderate limitations. Sites classified Provisionally Suitable require some modifications and careful planning, design, and installation in order for a ground absorption sewage treatment and disposal system to function satisfactorily. (c) Sites classified UNSUITABLE have severe limitations for the installation and use of a properly functioning ground absorption sewage treatment and disposal system. An improvement permit shall not be issued for a site which is classified as UNSUITABLE. However, where a site is UNSUITABLE, it may be reclassified PROVISIONALLY SUITABLE if a special investigation indicates that a modified or alternative system can be installed in accordance with Rules .1956 or .1957 or this Section. (d) A site classified as UNSUITABLE may be used for a ground absorption sewage treatment and disposal system specifically identified in Rules .1955, .1956 or .1957 of this Section or a system approved under Rule .1969 if written documentation, including engineering, hydrogeologic, geologic or soil studies, indicates to the local health department that the proposed system can be expected to function satisfactorily. Such sites shall be reclassified as PROVISIONALLY SUITABLE if the local health department determines that the substantiating data indicate that: (1) a ground absorption system can be installed so that the effluent will be non-pathogenic, non-infectious, non-toxic, and non -hazardous; (2) the effluent will not contaminate groundwater or surface water, and (3) the effluent will not be exposed on the ground surface or be discharged to surface waters where it could come in contact with people, animals, or vectors. The State shall review the substantiating data if requested by the local health department. History Note: Authority G.S. 130A -335(e); Eff. July 1 1982 Amended Eff. April 1, 1993; January 1, 1990. • 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: Susan Park Proposed Facility: Residence ATC Number: 5117 OPERATION PERMIT Tax PINIEH #: Subdivision Into: Location/Address: Property Size: 5851-26-8843.2 Sugar Valley Airport Lot # 2 249 Gilbert Road -27028 1.209 Acres **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. Y YP System Type: S.T. Manufacturer M 0 Tank Date Tank Size Pump Tank Size System Installed By: J C, oft t e � 0 s! VW f>E.H. Specialist: ate: GPS Co inate:\ `1 -2',�a,�Lt J DCHD 11/06 (Revised) B 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 #: 5851-26-8843.2 Billed To: Sugar Valley Airport Subdivision Info: Sugar Valley Airport Lot # 2 }deference Name: Susan Park LocationiAddress: 249 Gilbert Road -27028 Proposed Facility: Residence Property -Size: 1.209 Acres Site Type: ❑New ❑Repair ❑Expansion ATC Number: 5117 **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_I ( Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats ' Square Footage(or Dimensions of Facility) Q �'e Lot Size I. 10 / Type of Water Supply: ❑County/City 2-v eII ❑CommunityWell System Specifications: Design Wastewater Flow (GPD) ��y Tank Size & _AL. Pump Tank —NAAL. f Trench Width 36 " Max. Trench Depth 3 & Rock Depth Linear Ft. Site Modifications/Conditions/Other: Contact the Davie County Environmental Health Section for final inspection of this system between 9:30 — 9:30a.m. on the day of installation. Teleahone # (336)751-8760. . Environmental Health Specialist. DCHD 11/06 (Revised) s_ DAVIE COUNTY ENVIRONMENTAL HEALTH � P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 Account #: Billed To: Reference Nance: Proposed Facility: AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION 990005528 Sugar Valley Airport Susan Park Residence ATC Number: 5117 Tax PINIEH #: 5851-26-8843.2 Subdivisiort Info:.- Sugar Valley Airport Lot # 2 .: LocationiAddress: 249 Gilbert Road -27028 Property,Size: 1.209 Acres Site Type: 21ew ❑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 0L # People 1 Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) C� rc 3iLot Size ,- ` Type of Water Supply: ❑County/City-5W 1 �Coommugity Well 6 .Exp 5 System Specifications: Design Wastewater Flow (GPD) Dank Size AL. Pump 19 1 Tan'lc GAL. Trench Width 3L Max. Trench Dept_ Rock Depth (ofLinear Ft. 3a � Site Modifications/Conditions/Other: �'y ^ C vJ`^ I Irl et `fd / C � l s Contact the Davie County Environmental Health Section for final inspection of this system between JW $:30 — 9.30a.m. on the day of installation. Telephone # (336)751-8760. , r r I 75„ l as i b d Y e nv r �ecialist � Date: (Revised) 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 dame: Susan Park Proposed Facility: Residence OPERATION PERMIT Tax PIN/EH #: 5851-26-8843.2 Subdivision Info:"'Sugar Valley Airport Lot # 2 LocalioniAddress: 249 Gilbert Road 27028 Properly Size: 1.209 Acres ATC Number: 5117 **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: • • ' • 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 #: 5851-26-8843.2 Billed To: Sugar Valley Airport Subdivision Info: Address: 249 Gilbert Road Location/Address: 249 Gilbert Road -27028 City: Mocksville Property Size: L A04 etc I--- Reference -Reference Name: Susan Park 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 onstruction/installation of a wastewater system or the issuance of a building permit(in compliance with rticle 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to evocation if site plans, plat or the intended use change. it Type: L ew ❑Repair ❑Expansion Permit Valid for: CC'S Years ❑No Expiration Specifications: # Bedrooms # Bathrooms # People 7 Basement❑ Basement plumbing❑ on -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) lesign Flow(GPD):�4y Type of Water SuppIY: ❑Coupt/CitY 2%611 � OCIO'm uni nWell As stated in 15A NCAC 18A.1969(5) 1 ite Modifications/Permit Conditions: acceoted Systems may also be used lAA System Type LIAR �l Initial nC .e& _ Repair eC � - –jQ'— y 4< _y she ( p �,;e7. gx -� �t'Ca Environmental Health Specialist Date i.p.11.06 01 Nplication For:Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) O Both Type of Application: ❑New System 0Repair 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/t/ Name on Permit/ATC if Different than Above, Mailing Address Contact PersonSrV _ Home Phone cz% - a 9 7/ Business Phone 70? ;z - } j Z, PROPERTY INFORMATION -41' o/- , *Date House/Facility Corners NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 in W�eee, site pl , no expira}on with complete plat.) ` Owner's Name �fit' Phone}`�um er �� —:517/ Owner's Address City/State/Zip Property Address City7-7 C -Z Lot Size Tax PIN# Subdivision Name(if a plicable) Section/Lot# Directions To Site: 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-E6 Does the site contain jurisdictional wetlands? ❑Yes f550 Are there any easements or right-of-ways on the site? ❑Yes-B'NC' Is the site subject to approval by another public agency? ❑Yes t71�o Will wastewater other than domestic sewage be generated? ❑Yes,dNo IF RESIDENCE FILL OUT THE BOX BELOW # People _Q, # Bedrooms Z_ # Bathrooms Garden Tub/Whirlpool OYesxNo Basement: ❑Yes o Basement Plumbing: 0Yes 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: 21r onventional ❑Accepted ❑Innovative ❑Alternative ❑Other. Water Supply Type: ❑ County/City Water CJ New Well V&isting 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 an rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locati and flagging or st th se/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: