107 Meadow Brook Court Lot 41DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680
Account #: 990005949
Billed To: RS Parker Homes, LLC
Reference Name:
Proposed Facility: Residence
ATC Number: 6024
OPERATION PERMIT
Tax PIN/EH #; E8160A0041
Subdivision info: Meadows Edge Lot # 41
LocationiAddress: 107 Meadow Brook Ct.-27006
Property Size: .68
**NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC has been installed
in compliance with Article I 1 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: P, S.T. Manufacturer_ Tank Date 1012l Tank Size DOO
Pump Tank Size100D Bedrooms:[_
System Installed By �iAY�k Ir&VLSOInstaller# Date: 5" D
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
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990005949 Tax PIN/EH #: E816OA0041
Billed To: RS Parker Homes, LLC Subdivision Info: Meadows Edge Lot # 41
Reference Name: LocationiAddress: 107 Meadow Brook Ct.-27006
Proposed Facility: Residence Property Size: .68
ATC Number: 6024
Site Type: tdNew ❑Repair ❑Expansion
**NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental
Health Section prior tp 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 PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat
or the intended use change.
Residential Specifications: # Bedrooms t # Bathrooms_@�S- # 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 ❑ Well ❑ Community Well
System Specifications: Design Wastewater Flow (GPD) H@_Tank SizeJCQ0 GAL. Pump Tank ZurxIGAL.
Trench Width Max. Trench Depth( nRock Depth Linear Ft.7;yq A,
Site Modifications/Conditions/Other: d
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.
Environmental Health S
DCHD 11/06 (Revised)
�I
Davie Count'' Environmental Health
P.O. Bo 848/210 Hospital Street
M ksville, NC 27028
(336)753-6780 / Fax (336)753-1680
IMPROVEMENT PERMIT
I
Account #: 990005949 Tax PIN/EH #: E816OA0041
Billed To: RS Parker Homes, LLC Subdivision Info: Meadows Edge Lot # 41
Address: 502 Hickory Ridge Drive Location/Address: 107 Meadow B.-wi .(if - -27006
City: Greensboro, Property Size: 68
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 l l 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: ®New ❑Repair ❑Expansion Permit Valid for: 05 Years ❑No Expiration
Residential Specifications: # Bedrooms _ # 13athrooms2b # People -LL Basement Basement plumbing
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(of Dimensions of Facility)
Design Flow(GPD): _ Type ofVater Supply: ;KCounty/City ❑Well ❑Community Well
Site Modifications/Permit Conditions:
System Type LTAR
-,
93
Environmental Health Specialist
i.p. 11-06
Date Q
BEAUCHAMP RD. _
(60' R/*r PUBLIC) S88° 15 '56"E
10'x{10' SIGHT IF.� 133.89'
S87033' S`"
.RAD= 729.89'
SETBACKS:
FRONT: 30' 127.01'
SIDE: 15' MEADOW CREEK COURT
RSTREET EAR:
25'
EAR: 30 (50' ROF PUBLIC) PRELIMINARY
PLOT PLAN FOR:
RSP BUILDERS
LOT 41 OF MEADOWS EDGE, PHASE 2
P.B. 8 PG. 259
GRAPHIC SCALE
30 0 15 30 60
( IN FEET. )
1 inch = 30 ft.
Fleming Engineering, Inc.
700 Carnegie Place Greensboro, NC 27409
Phone: 336.852.9797 :•,Fax: 336.852.9766
NCBELS C-0950 DATE: 01-07-2013
REF: PROJ\1831-01\dwg\LOT 20 ... MtAUUWS tUUt.Owg
20 x20 SIGN 15'
LANDSCAPING EASEMENT
SEMENT
SETBACK
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50.83'
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PROPOSED 41
c°
2.00'
RESIDENCE 00
co cn tv
CJ1 � CA
O W
J
rn
126.0'
13.17' rn
22.83'
`'
16.83'
49.7'
�
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20' PUBLIC
o
L 10' UTILITY EASEMENT
DRAINAGE ESS MT.
10 X�SIG T ES T
N89° 15' 57" W
SETBACKS:
FRONT: 30' 127.01'
SIDE: 15' MEADOW CREEK COURT
RSTREET EAR:
25'
EAR: 30 (50' ROF PUBLIC) PRELIMINARY
PLOT PLAN FOR:
RSP BUILDERS
LOT 41 OF MEADOWS EDGE, PHASE 2
P.B. 8 PG. 259
GRAPHIC SCALE
30 0 15 30 60
( IN FEET. )
1 inch = 30 ft.
Fleming Engineering, Inc.
700 Carnegie Place Greensboro, NC 27409
Phone: 336.852.9797 :•,Fax: 336.852.9766
NCBELS C-0950 DATE: 01-07-2013
REF: PROJ\1831-01\dwg\LOT 20 ... MtAUUWS tUUt.Owg
Davie County, NC - GoMaps Advanced
+
77
BEAUU'r-ANIP RD
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28
1�8
108
16'7
EK CT
Page 1 of 1
MEADOW 811
4
117
z
Latitude; 35° 53` X5,31" Lorigi+.ude; -80126 10.
http://maps.roktech.net/davic_gomaps/index.html 1/31/2013
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Environmental Health
P.O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780/ Fax (336)753-1680 4stemor
Application For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To ct (ATC)
Type ofApplication: ❑NewSystem ❑Repair to Existing System ❑Expansion/Modificationo Facility
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPT,TCANT INFORMATION
Name L L Contact Person � y:'� ACLOA—
Address
�` , Ue srle 33Co -c`31i/-665P9X3oG
City/State/ZIP bdn ML LiVO9 Business Phone 336 - zCo 7 - F3 8 / Z
Email rs cox
Name o ermit/ATC if D fferent than Above
Mailing Address City/State/Zip
r1'VrM'UL T 11Nr VK1V1A 11V1N
-Late House/racinty. corners
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
(Permit is valid for 60 onths with site plan, no expiration with complete plat.)
Owner's Name P5 1(�t e LL L Phone Number 3_3fo %p 8/
Owner's Address City/State/Zip
Property Addre Tom"
Lot Size'
Subdivision Name(if applicable) �tion/Lot# �9/&OA Coq
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 _N -o--
Does the site contain jurisdictional wetlands?
_Yes �—No
Are there any easements or right-of-ways on the site?
Yes �-No
Is the site subject to approval by another public agency?
_Yes --No
Will wastewater other than domestic sewage be generated?
_ Yes -No
TF RESIDENCE FTT,T, OUT THE BOX BELOW
# People#Bedrooms # Bathroos — Garden Tub/Whirlpool es ❑No
Basement: ❑Yes DNo Basement Plumbing: ❑Yes 9?1
TF NON -RESIDENCE FITJ. 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: 9Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: CCounty/City Water ❑ New Well ❑Existing Well 0 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 applicat' ' falsified or changed I hereby grant right of entry to the Authorized Representative
of the Davie Co ty He Dep a to c duct necessary inspections to determine compliance with applicable laws and rules.
I understand es p nsi for a per identification and labeling of property lines and comers and locating and flagging
or staking s a . ty 1 io p osed well cation and the location of any other amenities.
Prope owner's or owner's legal representative signature Site Revisit Charge
Date(s):
Client Notification Date:
Date EHS:
Sign given ❑Yes []No Account #
Revised 11/06 Invoice # z
�� J
D
5 2004 1 f'LIcAnON 1011 SIM 1:VALUilT10NIIAil'ItUVL-Ail_N'f I'L'1A111T & 11TO
r�AR Davie County Health Department
Eiwir0M 11enta/Hea/t/1 Section
ENVIRONMENTAENFAE P.O. Dox 040/210 Hospital Street
DAVfECOU Mocksville, ITC 27020
(336)751-0760
L- ..
* * *I1•lPORTANT * * * TUIS APPLICATION CANNOT DE PROCESSED UNLESS ALL TILL REQUIRLD - I
INFORMATION IS PROVIDED. Refor to the INFORMATION DULLETIN for inot uction
J s
1. Home to be Dilled
nailing Address
City/;,tate/'LIP
Jade Associates II, LLC Alan one
COnLaCL 1'crson ..Y_..._....
Post Office Box 4062 110111e 11110110 _
Ilinston-Salem, NC 27115-4062 (336) 759-9688
Dusilless 11110110
2. Namo on Permit/ATC if Different than Above
Nailing Address Ci Ly/State/Zip
1. Application For: M Site Evaluation ❑ Ilnpz'ovcmcnL- Pe1iniL/ATC U ]loth
4. Syztem to Service: ® House ❑ Mobile Home ❑ Dusinc:;D ❑ Ilidus•L2y ❑ OL•11e; ...........
S. Type system requested: Ill Conventional ❑ conventional modified ❑ innovative
6. If Residence: 11 People 4 Ii Dedrooinr. 4 II DaLhro0111 2.5
tDiDlixasher InGarbage Disposal nNashing Machino Ell) a-emenL/1'lwubing ®Da.,;emenL/110 1'lulubing
7. If Duainess/Industry /OLt:cr: verify type 11 1'coplc 11 OiuL:;
N Commodes a Showers 11 Urinals 11 WaL'er Cooluru
IF FOODSERVICE: It SeaL'a EDLimaLed Water Usagc (gallons par day)
8. Type of water supply: 0 County/City ❑ well ❑ Couuuuni tyws
9. Do you anticipate additions or C\p:111si0llS Uf the facility this s)'stClll is ill(cllded (U Seiwc'? ❑ Yes dl No
if )'es, 11 -hat type?
IAII'01MINY" CLIEN'I'Sd1USTC0i11P. L-TL-'r)IL 1L•'QU11(L•'U 111(01'ERTY INFORMATION REQU1ESTI-A) —
13CLOW. Either a PLAT orSITE PLAN AIUSTBE- SUMV17-1777 by the elicit lrieh'1'FIIS A1'1'l,IG1'I'ION.
1'ruperly Dimensions:
See attached map
Tax Office 1'IN: /I 5871615955
Property Address: Road Nanlc Beauchamp Road
City/Zip
Advance, 27006
WRITE' VIRLCTIONS (frurll Aludwille) lu I'RUI'I-.'R .V:
East on flighway 158, turn right onto
Gun Club Road and proceed to the end of
the road, turn left -onto Beauchamp Road
If ill a Subdivisioll provide illfOrnlatioll, as fullulvs: and the site is located approxi mately two
Nall1c: Proposed Jade.Associates miles down Beauchamp Road on the right and
Scciioal: Bloch:
41 left side of the road. 3/8/04
Lot: '-4-(�—•n Datc Value corners fa6ged:
This is to certify that (lie information provided is correct to the best ol'iuy luloll•ledge. 1 understand that any pernlil(s)
issued hereafter are subject to suspcusion or revocation, if the site plallS or ilitcndcd use cil:ulge, or if the iufuriilaliou
submitted ill this applica(iou is falsified or changed. I, also, untle'stanit that I ant reipunsible fur «ii chaib'es ilicurred from
this application. I, hereby, give consent to the Authorized Representative of (lie D:lvie Cullllly I1ca101 1)eI"
'(11
to cuter upon above described prupcl'ly luca led in Davie County and ulrncd by Jade Assoc1 ates ! I , Ll�
to cunducl :111 testing procedures as necessary to determine the site suitability.
DATL 3/15/04 . SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Llclude all of the fullowing: Exis(ing and prupuscd
properly lines and dinlensions, structures, setbacks, and septic locations).
Site Revisit Charl;e
Datc(s):
Client Nolificatiuu Date:
IEIIS:
Sign given
A "'n.... t Tr.,