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640 Beauchamp Rd DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hosp}tl Street Mocksville,NC 27028 (336)753.-6780/Fax#(336)753-1680 OPERATION PERMIT Account #: 990005866 Tax PINIEH#: F80000000805 Billed To: Jeremy and Sara Stanley Subdivision Info: . Reference Name:. Location/Address: Beauchamp Rd-27006 Proposed Facility: Residence :;`: Property,Size: 2.778 Acres ATC Number: 5932 **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 Tank Date Tank Size Pump Tank Size� Bedrooms: A,— System System Installed By: f�1I> �}�Ma(_' n Installer# Date: 1111W,902 GPS Coordinate: 3 lit'iC k16t Environmental Health Specialist 'AM) Date: p 2©/Z 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 #: 990005866 Tax.PINfEH#: F80000000805 Billed To: Jeremy and Sara Stanley Subdivision Info Reference Name: ... . . , ; LocalionlAddress: Beauchamp Rd-27006 Proposed Facility: Residence :Proper#y Size: 2.778 Acres - - ATC Number. 5932 Site Type: ❑New ❑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) Lot Size-at 71&C Type of Water Supply: bounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD)2(C()Tank Size GAL.Pump Tank GAL. Trench Width 6 Max.Trench Dept1&Q_ Rock Deptf"'- Linear Ft. Site Modifications/Conditions/Other: Contact the Davie County Environmental Health Section for final inspection of this system between. 8:30—9:30a.m.on the day of installation. Telephone#(336)751-8760. OWN Environmental Health SpecialistO Date o? rerun 11 rnr,Mpvicpd) . Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680. IMPROVEMENT PERMIT Account #: 990005866 Tax PIN/EH M F80000000805 Billed To: Jeremy and Sara Stanley Subdivision Info: Address: ' 380 Luzele Drive Location/Address: Beauchamp Rd-27006 City: Winston-Salem Property Size: 2.778 Acres Reference Name: 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 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: 04ew ❑Repair ❑Expansion Permit Valid for: Y5 Years ❑No Expiration _ Residential Specifications: #Bedrooms3 #Bathrooms 1 #People _Basement❑ Basementplumbing ❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):_'3&0 Type of Water Supply: County/City ❑Well ❑Community Well Site Modifications/Permit Conditions: _ S stem Tym.. LTAR Initial Repair Site Plan - j P y6s- Environmental Health Specialist ODated i.p.11-06 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O.Box 848/210 Hospital Street P E G E E Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 A APR � P Applic i n r. i e 1 ati mprovement Permit ❑ Authorization To Construct(A oth Type o plication: ew Sys ❑Repair to Existing System ❑Expansion/Modification of Existing este cih ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name d— Contact Person Address Home Phone p-02 Bpq City/State/ZIP C Business Phon `l l Email 6 J. te�tCFPf) b6hmail-rary-% Name on Permit/ATC i Dierent than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facili Corners Flagged qLZ-3 I-. 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,no expiration with complete plat.) Owner's NamePhone Number $1�-0Z3G Owner's Address�M___1-1 City/State/ZipWIt1Sjw,52JDM N(,Z`1103 Property AddressRzeauctamp 12d- CityAd n P_, (`(� Z-(��e Lot Size 2.1-78 Grye Tax P # fG i Subdivision Name(if applicable I GL Section/Lotff n I Directions To Site: 1-40 d, a� t If th6 answer to any of the followiig questions is"Yes",supporting docuontation musta attach : Are there any existing wastewater systems on the site? _Yes _No Does the site contain jurisdictional wetlands? _Yes 7No IS Jra`tC� -� Are there any easements or right-of-ways on the site? _Yes 2No Is the site subject to approval by another public agency? _Yes ✓No Will wastewater other than domestic sewage be generated? Yes ✓No IF RESIDENCE FILL OUT THE BOX BELOW #People 3 #Bedrooms 3 p 1-#Bathrooms 311- Garden Tub/Whirl ool ❑Yes o Basement: V`Yes ❑No Basement Plumbing: & Yes ❑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: M'Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ecounty/City Water ❑New Well ❑Existing 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 into 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 comers and locating and flagging or staCd4 the house/facility loca' n,proposed w 11 location and the location of any other amenities. Prope ve owner's or owner's legal representa ignature Site Revisit Charge Date(s): 2- Client Notification Date: Date I EHS: f25 Pct GoMAPS - Davie County NC Public Access -�`� WATERSHED STRUCTURES WATER "BODIES 218 COUNTY-BOUNDARY PARCEL DIMENSIONS STREETS t \ <� RAILROAD_CENTERLINE PARCELS vU�J � POND LN- CITY LIMITS + I yt BERMUDA RUN COOLEEMEE H / f �} DAVIE COUNTY MOCKSVILLE ti 149 ' r�1 yu 2133 ` /,f '.�r✓ 1z" .l j —,v 326 . —_.70 L�9S�� N N a > 570.75_1 F It' 6 13 � e MOCKS CHURCH RD cl 374.36'22Q 5t, -lr++ +I i Tuesday,April 24 2012 \ASSB t S: • Do29F1-��-T1F�� I1 `�I \ 1,1 ***WARNING:THIS IS NOT A SURVEY!*** This map is prepared for the inventory of real property found within this jurisdiction,and is compiled from recorded deeds,plats,and other public records and data.Users of this map are hereby notified that the aforementioned public primary information sources should be consulted for verification of the information contained on this map.The County and mapping company assume no legal responsibility for the information contained on this map. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990005866 Tax PIN/EH#: F80000000805 Billed To: Jeremy and Sara Stanley Subdivision Info: Reference Name: Location/Address: Beauchamp Rd-27006 Proposed Facility: Residence Property Size: 2.778 Acres Date Evaluated: Water Supply: On-Site Well Community /k Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % 4 O HORIZON I DEPTH _y - 0-36 Texture group Consistence _ , Structure Mineralogy HORIZON H DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH r Texture group Consistence - - Structure ' Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION P $ LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: jr� EVALUATION BY- AIWA&%l 2)Ag'fi4&l1& 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 loamSIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE �1SI 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 Minerals. 1:1,2:1,Mixed LYQtes . Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface Saprollte-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 05105(Revised) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■e■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■c■e■e■■e■■e■■eee■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■e■arae■■■e■■■e■e■■■■■■■■■tt■■e■e■e■e■■■■■■■ ■■■■■■■■■■■t!■■■■■■■■■t::.a■■■■■■I�■■■■■■■■e■■■■■■■■■■I■■■eee■■■■■■■■■■■ ■■■e■■e■s■■■iecae■e■■■■c■■c■■ail■■!�■■■s■■e■e■e■e■■i■■■■■■■■■■■■■e■■■ ■■■■■■■■■■■■I■■■■■■■■■■■■■e■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ecce■ ■■ee■s■■■■■■tl■■■■■■■■■■■■I■■■■■■■■■■ecu■■■■■■■■■■■c■■■■■e■■■■■cc■■■ ■■■■■■■■c■■■■It■■■■■c■c■■■■■■■■■■■■■■■■■■■■■■■■■■!.1■■■■■■■■eee■■■■■■ ■■■■■■■■■■■■■■■e■■■■■■■■■■■■■■■■■c■■■ee■■■■■■■■■■eee■■■■■■■■■eee■■ ■■■■■■■■■■■■■■■1!■■■■■e■■■■■■■■■■ ■e■■■■■■■■■■■■■c■■■■e■■■■■ecce■■ ■■■■■■■■c■■■■■■■tl■■■■■■■■■■■■■■■■e■■■c■■■■■■■■enc■■e■■■■■■e■■eee■■ ■■■■■■e■■■■■■■■■�i■■■■■■■■eee■■■■■■■■■■■c■■■c■cc1!■c■■ec■e■■■■c■■■c■ ?J NMO o` ri 0/0 OZ u� v V � L �i 1 � ' JJ' ti • _ ` /Iyf v�� �vd ow n a Pp S Re6idential Standard NoteIs t��! fill fit Mz �' =� "� �---�� -. __._.. _ -�• illi ` c4vmgD r6 L j; ' ,.. ; .a � +r 0 i VIE 2. b ._...� ....._.«... ' om,r r 1-pMiin . 41 - 401 FIRST FL0012 PLAN 1.Mf M. ..r..rw •`� wa ~ .�•w 4M TTP.DRICK VENEER WALL&WTION WM"EMENT _ _ •„ ,uur ata un 403 VWK WALL X lECTON . w�wr aw.�..s.ua .'..•,.ra 4 - ProBrw pemN� j e t j r1 itill ------------------ � r tf ° g ...N . - ® l' .'" _________ __----------------- -------------------- ___ ----- -------• wd 't .......... ....... WATWF F rr975 1 � � W.I.G. �LLCONY P 501 SECOND FLOOR PLAN n1 CIO 3 Vv n iso Z�c4 yp ISI . '` Zr