The URL can be used to link to this page

1221 Beauchamp Rd HEALTH DEPARTMENT RELEASE ." For , 77 use only `CDP File Number .140025- 1 Davie County Health Department lot 210 Hospital Street Coun ,Ip Number P.O. Box 848 Evaluated For HDRA"C. Mocksville NC 27028 Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID 0 8 / 0 5 / 2 0 1 9 UNTIL Applicant: James C Bailey Property Owner: James C Bailey Address: 1221 Beauchamp Road Address: 1221 Beauchamp Road City: Advance City: Advance State2ip: NC 27006 State2ip: NC 27006 Phone#: (336)998-4538 Phone#: (336) 998-4538 Property Location& Site Information FAddres�l22l Beauchamp Road Subdivision: Phase: Lot:d#Advance NC 27006 SINGLE FAMILYTownship: cture: Directions #of Bedrooms: 3 #of People: Hwy 158 East to Baltimore rd.right on Baltimore to Beauchamp on left. 1221 is 1/2 mile on right 'Water Supply: N/A Type of Business: Basement: �Yes�No Total sq. Footage: No.Of Employees: 'Proposed Improvement: Storage building '�MaisnetaCin nditions R.= 5 foot setback to any portion of the septic system. . 6� This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps.Signature Required? Oyes ONO Applicant/Legal Reps.Signature: __ 'Date: 'Issued By: 2140-Nations,Robert 'Date of Issue: 0 8 0 5 / a 0 1 4 Authorized State Agent: **Site Plan/Drawing attached.** _ - Gall dffl�l fhirV a�� 1�►e Davie County Health De � r 4' Environmental Health Section , ts� , ': • PAID P.O. Box 848 f ,� 210 Hospital Street p � .. Courier# : 09-40-06 t ` Mocksville, NC 27028 Phone:(336)-753-6780 Fax:(336)-753-1680 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Name: ! Phone umber s 6 ��6�-� �3�� (Ho e) Mailing Address1_2 d2t°AllCw/;ir! ap A V, e-e 22 D D of Email Ad Detailed Directions To Site:��57 4— 10 Al 1-5-e * �? -� Y ` m AI; /1'pc��+C 7'6*- 6Aq e-, �7 cert( l�' � �� O 1 l%'-w"G /Ll I' 2/ l s 2 1771'le Property Address: Please Fill In The Following Information About The EXISTING Facility: 4,1147 �- Name System Installed Under: �e V Type OfFac ility:le DO Vit/ ;74��,r Date System Installed(Month/Date/Year): DNumber Of Bedrooms:- Number Of People:_ Is The Ficility Currently Vacant? Yes fT If Yes,For How Long? .Any Known Problems? Yes & If Yes,Explain: Please Fill In The F llowing Information About The NEW Facility: Type Of Facility: ('(.[' Number Of Bedrooms: Number of People Pool Size: Garage Size: Other: Requested By: 010Date Requested: (Signature) For Environmental Health Office Use Only Disapproved Comments: Environmental Health Specialist Date: *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: CashCheck Money Order # Amount:$ Date: y Paid By: Received By: Account#' Invoice#: CO r 1 0 7 � �� ! 5 r Arolp --- ....�_..._ s -- — rr j (2 60) 40 i d'• 1221 Q o4 7Le",M V q I .fir 7['i l l —4 /10 �� *) i. CO UK Printed:Jul 21 , 2014 All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie, North Carolina,its agents,consultants,contractors or employees from any and all claims or causes of action due to or arising out of the use or inability to use the GIS data provided by this website. DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,.NC 27028 (336)751-8760 Account #: 990000764 Tax PIN/EH#: 5871-13-0277 Billed To:. ,lames.Bailey . Subdivision Info: Mll Reference Name: Location/Address: Beauchamp Road-27006 Prd osed Facility: Residence' Pro a Size: see ATC Number: 4342 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 1of G.S. Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: 'y `� Date: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improyement/Operation Permit 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 systemwillfunction satisfactorily for any given period of time. Y e %b E`- P�c•4 � �1t��ir�rEa.E.�ct? Septic System Installed By: Environmental Health Specialist's Signature: Date: O&M DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990000764 Tax PIN/EH#: 5871-13-0277 Billed To: James Bailey Subdivision Info: Reference Name: Location/Address: Beauchamp Road-27006 Proposed Facility: Residence Property Size: see ma ATC Number: 4342 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: � '' �� Date: �p CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit 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%�-�"` T_ft I� ' 10AAA �L U W�,37,!V t ,BaG�iereae.Pk Septic System Installed By: Environmental Health Specialist's Signature: 4 Date: DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 ( I� (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000764 Tax PIN/EH#: 5871-13-0277 Billed To: James Bailey Subdivision Info: .Reference Name: Location/Address: Beauchamp Road-27006 Proposed Facility: Residence Property Size: see map / ibm4342 **NO Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type // #People #Bedrooms #Baths 2. Dishwasher:Aff- Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size S. Type Water Supply Design Wastewater Flow(GPD)`cf Site: NewEr_Repair❑ System Specifications: Tank Size/GAL. Pump Tank GAL. Trench Width Rock Depth Linear FtbIO Other: As stated in 15A NCAC 18A.1969i:. Required Site Modifications/Conditions: accepted Systems may also be used IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6 11 BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** Environmental Health Specialist's Signature: Date:—3g/®( /g DCHD 05/99(Revised) pp "UCATION FOR SITE EVALUATION/IMPRBVEMENT PERMIT&A , S ;. D Davie County Health Department O Env1Wtimental Heath Section , P.O. Box 848/210 Hospital Street L Mocksville, NC 27028 (336)751-8760 n * ORTLur** IS AT KATION CANNOT BE PROCESSED UNLESS ALL THE RE�t! RED` ORMF_A�v�TnW�2,TA!2 5�` RO D. Refer to the INFORMATION BULLETIN for instructions.— ,' 1. Name t!. o"be �Sn /�j/��(/ Contact Person i I/ ing Address _��? /�Pjl�Gr//}�ry.�O �j� AV Phone City/state/ZIP EJ /y f oe� Ale-, -7 70 Oh Business Phone33 S �� 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: XSite Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: f House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People _ # Bedrooms # Bathrooms 2 DC Dishwasher U Garbage Disposal �4Q Washing Machine Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type'of water supply: County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes NNo If yes,what type? ***IdfPORTANT LI S MUST PLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELO Either a PLAT or SITE PLAN�USTBESUBMITTED by the client with THIS APPLICATION. Property Dimensions: E A �72rAPs WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: # !�X L / - tR - o cam,L 7' f-1 02, 7' e4l Z Property Address: Road Name I-Tego e i, f M 0 City/Zip 7 1t9ZV d4✓ If in a Subdivision provide information,as follows: 177illf' y Name: /1 i WI-1-AlI-1- AlWil &1leWlU .�N, la]' Section: Block: Lot: Date Pr6perty Flagged: 0-:2L This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or if the information submitted in this application is falsified or changed. I,also,understand that I am responsible for all charges incurred from this application. I, hereby,give consent to the Authorized Representative of the Davie County:Health De art nt to enter upon above described property located in Davie County and owned by r7i� ,!P eS r�� to conduct all testing procedures as necessary to determine the site suitability. DATE ^/ — 4 SIGNATURE 4 THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): -" Client Notification ate: EHS: -- r _ - Account No. 7�2 Revised DCHD(07/99) - Invoice No. s _Inuoice* co 107 35 747 150 260 (154) BEAUCI-IgMP (260) ROAD 40 (1 .01A) N 7314 co A) � 0277 E700000141 15p o C.0 00 J � � (8.56A) �� 8905 DAVIE COUNTY HEALTH DEPARTMENT �. Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990000764 Tax PIN/EH#: 5871-13-0277 Billed To: James Bailey Subdivision Info: Reference Name: Location/Address: Beauchamp Road-27006 Proposed Facility: Residence Property Size: see map Date Evaluated: Water Supply: On-Site Well Community Public v� Evaluation By: Auger Boring ✓ Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe% HORIZON I DEPTH Texture groupS Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure i Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: l/ LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: LEGEND 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 oist VFR-Very friable FR Friable FI-Firm VFI Very firm EFI-Extremely firm Wet 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 05/99(Revised) L r - 111 COUNTY ii I.T I D � 14F. ` ENVIRONMENTAL HEALTH SECTION P. 0. Box 848/210 Hospital Street Courier #09-40-06 Mocksviile, NC 27028 Phone #: (336)751-8760 March 15, 2002 James C. Bailey 1162 Beauchamp Road Advance,NC 27006 Re: Site Evaluation/Beauchamp Road Tax Office Pin: # 5871-13-0277 Dear Client(s): As requested, a representative from this office visited the aforementioned site on March 14,2002. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site, the site was found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions,please feel free to contact this office. Sincerely, Robert B. Hall, Jr., R.-S. Environmental Health Specialist RWdf JS 1191 , ,W0-102— ,Ot—,£ ,Z—,ZIP 6—,E 0 If O o , 42—,9 OO O� ,S—,8 J O HSVM j FRIG I HSIQ 1' !--- ,Ot—,Ei---��/�E—IL �L—IZr-----• /�9—/iT� I Iz—,Zt� t