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Gilbert Road Lot 3 - DuplexDavie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Account #: 990005528 Billed To: Sugar Valley Airport Address: 249 Gilbert Road City: Mocksville Reference Name: Proposed Facility: Duplex 1� Tax PIN/EH #: 5851-26-8843.03 Subdivision Info: Location/Address: Gilbert Road -27028 Property Size: 68 Acres **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An uthorization To Construct a wastewater system must be obtained from this office prior to the con ction/installation of a wastewater system or the issuance of a building permit(in compliance with article 11Qf G.S. Chapter 130A, Wastewater Systems). This Improvement rermit is subject to revocation i to plans, plat or the intended use change. Permit Type:., ew ❑Repair, ❑Expansion Permit Valid for: Years ❑No Expiration Residential Specifications: # Bedr s__�L # Bathrooms # People Basement❑ Basement plumbing❑ Non -Residential Specification . acility Type # People # Seats Sq%Footage(or Dimensions of Facility) Xe Design Flow(GPD): Type of W\ Supply: ❑County/City B'We"11 ❑Cotfimunity Well As stated in 15A NCAC 18A.1969(5 Site Modifications/Pennit Conditions: accepted S at Site Plan Initial Environmental Health Specialist i.p. 11-06 INII:11:1 t–t- a .a d I , %_ — Date Application For: /Site Evaluation/Improvement Permit Authorization To Construct(ATC) Z Both Type of Appliption, F,]New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility * * *IMPORTANT* * * THIS APPLICATION CANNOT BE PROCESSED UNLESS ALYVT )b QM*A INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instrct APPLICANT INFORMATION ± U L1 J U L 2 12010 IUJI Name to be Billed t- 4 4Contact Perso Billing Address Home PPho City/State/ZIP O M B=Vhone Name on Permit/ATC if Different than Above Mailing Address PKUPHKI'Y 1NFUKMA'Y10N '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 months/with site plan, expiration ` 'complete plat.) Owner's Name (/ / �� /� Y Phone Number ! 9� • 3 9 71 Owner's Address 2�9 �i ,E�e&Z 4t City/State/Zip IJ C-2 Property Address City 7-702, Lot Size Tax PIN# ,V.5/- 7�- 3 Subdivision Name(if applicable) Section/Lot# Directions To Site: W "L ex. �y Gdvlc ,,0e_o_� _ex.Q " _ 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? 11-YesMNo APPLICANT INFORMATION ± U L1 J U L 2 12010 IUJI Name to be Billed t- 4 4Contact Perso Billing Address Home PPho City/State/ZIP O M B=Vhone Name on Permit/ATC if Different than Above Mailing Address PKUPHKI'Y 1NFUKMA'Y10N '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 months/with site plan, expiration ` 'complete plat.) Owner's Name (/ / �� /� Y Phone Number ! 9� • 3 9 71 Owner's Address 2�9 �i ,E�e&Z 4t City/State/Zip IJ C-2 Property Address City 7-702, Lot Size Tax PIN# ,V.5/- 7�- 3 Subdivision Name(if applicable) Section/Lot# Directions To Site: W "L ex. �y Gdvlc ,,0e_o_� _ex.Q " _ 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? 11-YesMNo Does the site contain jurisdictional wetlands? ❑Yes PN -0 Are there any easements or right-of-ways on the site? ❑Yes 08 Is the site subject to approval by another public agency? ❑Yes Will wastewater other than domestic sewage be generated? ❑YesllNo IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms R P Bathro Basement: ❑Yes �2No asement Plumbing: ❑Yes PN6o IF NON -RESIDENCE FILL OUT THE BOX BELOW Tub/Whirlpool ❑Yes 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: B'Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water ❑ New Well C,Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, what type? cm 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 a d rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locat g and flaggingo taking t house/facility location, proposed well location and the location of any other amenities. P perty owner's or owner's legal representative signature ✓✓ Site Revisit Charge __ -P, I3� Date(s): Client Notification Date: Aizp �. Rum wa y � A Building 1.1anger Build* Deck r of X Mo ilei x� D C/o rooms 1'0,3-E s0 pV z Building S'(� ` tib, Conaeb N0676'53 E 1 C7 C) 178.67' D, \ I NWei = eui/off n � aL 178.77' �9, �oLei �q� Building + 1/8• Ex. Iron �l 7 Z c m ;Buildin fUJ Wank.� g• N o 4 Blank o ^ 9G R/W Monument 3 844 n \ Building sig --lX _X � N 9G /ron pont X _` Well 3 X `9 k Oi 6112- N 12 4 , k --- G 5 8' Rebar �O CO rs£ 6 19" X ll 742.27• Deed 488.09, E X V Z \ Ex. Iron iw COP 9G I 3 E600000404 o Denise Cynthia Wfiaon 9G IDB 144—PG 501 CiUi thito BEGINNING of on existing iron e tthned�onotw ornforr J CO Ex. Ira, Sent Southwest corner of the prop y ow DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990005528 Tax PIN/EH #: 5851-26-8843 Billed To: Sugar Valley Airport Subdivision Info: Reference Name: Location/Address: Gilbert Road -27028 Proposed Facility: Duplex Property Size: 68 Acres Date Evaluated: Water Supply: Evaluation By: On -Site Well / Community Auger Boring / Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH 6 Texture group C C 15c- GConsistence Consistence Structure Mineralogy HORIZON H DEPTH Ite Texture group Consistence Structure K 1Q MineralogyQ HORIZON III DEPTH Texture rou Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE 8 or7 SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: LEGEND EVALUATION BY: / l 6 6. b 1 j Lok 7 OTHER(S) PRESENT: 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 �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 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_tarm ....1/.7..../h1 ■ ■ NOON///■■/■/■!!!'.7■//■//!!■ ■■■////NOON//►ifi■■/■■■/■ ■///■■/Nil!■/■�1it"._�'1//■■ NOON/■//■■I/■\�■//�■It■//■ ■EE■EEE■ NONE SEEM ■E■■ ■■■■■wwmwM ■E■■ENE■Ei ■■E■PR■■N■ ■E■ELFJ■■■ ■E■NIN►■■E■ ■■O■OOem■■ ■E■■E■E■E■ !mo■■■■■■■ ■■■■minman ■■■■■■■■■■ ■E■■E■■EN■ ■O■EEE■E■■ ■E■■■■E■E■ ■■■ ■EOE■ MEN MENEM ■■■ ■■/■■■■■■■■■■■�li�■■EO■■■■■■■■■■■■■■■■■■■■■■■■■■■/NOON■ ■■E■■■/■■■■■■res.I■■■■E■■■E■■■■■E■�i■w■■■■■■■■■■■■■■■■■ ■■s■EEE■E■E■�■.:7EE■EE■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■Iran,�■■■■■■■■w■■■■E/■�/■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■res■ri■■E■■EE■■■■■E■■■■■■■■■E■/■■■■■■■■■NEE■■ ■Eww■ww■ww■w�iw■■www>,i■wee'!w�•��■sww■■N■w■w■■w■■■■■■ Fe■ ■ ■limmil■ ■oI■ill■ ■i1■iu■ ■■■NEfI■■ ■■■E■NIE■ ■■ ■