108 Meadow Creek Court Lot 28HEALTH DEPARTMENT RELEASE
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_• Davie County Health Department
...� 210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: RS Parker Homes LLC
Address: 502 hickory Ridge Dr
City: Greensboro
StatefLip: NC 27409
Phone #:
Address 108 Meadow Creek Ct.
Road # Advance NC 27006
*Structure:
# of Bedrooms: # of People:
*Water Supply: PUBLIC
Basement: F]Yes ❑ No
*Proposed Improvement:
Detached Garage
For Office Use Only
*CDP File Number 80993 - 3
E8160A0028
County ID Number:
Evaluated For: HDR/WWC
PERMIT VALID 0 7/ 2 5/ 2 0 1 8
UNTIL:
Property Owner: RS Parker Homes LLC
Address: 502 Hickory Ridge Dr
City: Greensboro
StatefZip: NC 27409
Phone #:
ProperPropertv L n —Sifl o rm atio n
Subdivi on: MeadowsEd Phase: Lot 28
Township:
Directions
158 toward Advance, right on Gun Club Rd. and go to end turn left
onto beauchamp Rd. Meadows Edge on right.
Type of Business: Detached Garage
Total sq. Footage: No. Of Employees:
It is the responsibility of the owner to maintain a 5' minimum setback between the wastewater system and any part of the structure
foundation, including porches, decks, and any other appurtenances. If you are unsure as to the exact location of the septic system, please
have a licensed installer or inspector locate the septic system for you. The local county health department in no way implies that the
proposed construction meets the required setbacks from the septic system unless otherwise noted. This release only shows that this
property has an approved wastewater system that appears to have met the permitting requirements at the time it was installed.
repair area wil be below garage in between house and street. Repair system my have to be a 50% reduction system
This release in no way expresses or implies that the existing subsurface sewage treatment and dispose
system serving the site will continue to function for any period of time.
Applicant/Legal Reps. Signature Required? QYes ONo
Applicant/Legal Reps. Signatu
*Issued By: 2244 - Daywalt, Andrew
Authorized State Agent:
*Date:
*Date of Issue: 0 7/ 2 5/ 2 0 1 3
**Site Plan/Drawing attached.** Total Time:(HH:MM)
0 1 Hours 0 0 Minutes
G Hand Drawina OImport Drawina
0�pf roved. gAda 'h
Davie County Health Department 336—ZG 7-88�Z
Environmental Health SecOECEIVED
P.O. Box 848
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Phone: (336) - 753 - 6780 '¢e���
210 Hospital Street
Courier # : 09-40-06
Mocksville, NC 27028
JUL 2 3 2013
DC HEALTH
ON-SITE WASTEWATER CERTIFICATION
(Check One) ReplacementRemodeling Reconnection
Far: (336) - 753-1680
Name: R5 PckcrL Phone Number 3—:26 - AD 7- )Z (Home)
Mailing Address: 5,0Z{ idZ Or (Work)
Detailed Directions To
C(
Property Address: fee 6
Please Fill In The Following Informaation About The EXISTING Facility:
Name System Installed Under: P� I "I(Lk 14-wu� L -LC_ Type Of Facility:
Date System Installed (Month/Date/Year): / Number Of Bedrooms: Number Of People: �ff
Is The Facility Currently Vacant?Yes No If Yes, For How Long? f- ' It
Any Known Problems? Yes (NoD If Yes, Explain: r G
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: Number Of Bedrooms: Number of People
Pool Size: G ge Size: Other: 7
Requested By: Date Requested:_ n7/! ( 0/
Signature
For Environmental Health Office Use Only
Approved 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: Cask"--ChecZj Money Order # !I LI Amount:$ -
Paid By: Received By:_
Account #: Invoice #:
a
SETBACKS:
FRONT: 30'
SIDE: 15'
STREET SIDE:
REAR: 30'
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BEA UCHAMP ROAD (6o' R/W PUBLIC)
S88051'56"E 127.77'
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ECEIVED
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28DETACHED g P OPOSE�
DRIVE
GARAGE N
22.W \
15.25' \
13.33' g c
Y 22.25'
PROPOSED \
RESIDENCE
22.08'
C; 13.17'
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C,,H EALTH
0.75' N 13.17' n '� I
v 1
22.83' o
16.83'
— SETBACK
I
10' UTILITY EASEMENT — — —
N890 15' 57" W 166.97'
MEADOW CREEK COURT
(50' R/W PUBLIC)
GRAPHIC SCALE
30 0 15 30 60
( IN FEET )
1 inch = 30 it
PRELIMINARY
PLOT PLAN FOR:
RSP BUILDERS
LOT 28 OF MEADOWS EDGE, PHASE 2
P.B. 8 PG. 259
REVISED DATE: 07-17-12
Rminj 6linarmmg, Inc.
700 Camegle Place Greensboro, NC 27409
Phone: 33641524797 a Pax: 336.041766
NCBELS C-0950 DATE: 08-21-12
REF: PROJ\1831-01\dwg\LOT 28 MEADOWS EDGE.dwg
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0.75' N 13.17' n '� I
v 1
22.83' o
16.83'
— SETBACK
I
10' UTILITY EASEMENT — — —
N890 15' 57" W 166.97'
MEADOW CREEK COURT
(50' R/W PUBLIC)
GRAPHIC SCALE
30 0 15 30 60
( IN FEET )
1 inch = 30 it
PRELIMINARY
PLOT PLAN FOR:
RSP BUILDERS
LOT 28 OF MEADOWS EDGE, PHASE 2
P.B. 8 PG. 259
REVISED DATE: 07-17-12
Rminj 6linarmmg, Inc.
700 Camegle Place Greensboro, NC 27409
Phone: 33641524797 a Pax: 336.041766
NCBELS C-0950 DATE: 08-21-12
REF: PROJ\1831-01\dwg\LOT 28 MEADOWS EDGE.dwg
' DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 /Fax # (336)753-1680
OPERATION PERMIT
Account #: 990005949 Tax PKIEH #: E816OA0028
Bilied To: RS Parker Homes, LLC Subdivision Into: Meadows Edge Lot # 28
Reference Name: LocationiAddress: 108 Meadow Creek Court -27006
Proposed Facility: Residential Property Size: 34,500 Sq.Ft.
AT* *8 I E The9is8suance 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.
�kam6erl�Y
System Type.:_ S.T. Manufacturer13�OCJ Tank Date!j/2 Z Tank Size /aO D
Pump Tank Sized Bedrooms:_
System Installed By:, Installer# Date: 3 0 e?
....... _ 1.
GPS Coordinate:
gal
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Environmental Health
DCHD 11/06 (Revised)
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DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street �I p
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account M 990005949 Tax PIN/EH #: E816OA0028
Billed To: RS Parker Homes, LLC Subdivision info: Meadows Edge Lot # 28
Reference Blame: Location/Address: 108 Meadow Creek Court -27006
Proposed Facility: Residential Properly Size: 34,500 Sq.Ft.
ATC ('Number: 5980 Site Type: ONew ❑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 chance.
Residential Specifications: # Bedrooms_ # Bathrooms &Yz .# People Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility) _ _____
Lot Size 3 5W r Type of Water Supply: ❑County/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow (GPD) _Tank Size /qpo GAL. Pump Tank _AVpGAL.
Trench Width Max. Trench Depth -3V.' Rock Depth Linear Ft. 3 y0' acS��o
Site Modifications/Conditions/Other! —,kmp WLAC'b011
Contact the Davie County Environmental Health Section for final inspection of this system between
8.30 — 9:30n -m- on the day of installation- Telenhone # (3361751-8760.
En ironme tal Health Specialist Date: a� o�
_ DC 11/ 6 (Revised)
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En ironme tal Health Specialist Date: a� o�
_ DC 11/ 6 (Revised)
1
Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax (336)753-1680
IMPROVEMENT PERMIT
Account #: 990005949
Billed To: RS Parker Homes, LLC
Address: 502 Hickory Ridge Drive
City: Greensboro,
Tax PIN/EH #: E816OA0028
Subdivision Info: Meadows Edge Lot # 28
Location/Address: 108 Meadow Creek Court -27006
Property Size: 34,500 Sq.Ft.
Reference Name:
Proposed Facility: Residential
**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: XNew ❑Repair ❑Expansion Permit Valid for: 95 Years ❑No Expiration
Residential Specifications: # Bedrooms_ # Bathroomsc?i # People Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats_
Square Footage(or Dimensions of Facility)
Design Flow(GPD): 360 Type of Water Supply: L[County/City ❑Well ❑CommunityWell
Site Modifications/Permit Conditions:
S stem Type LTAR
Initial
Renair
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028 AV
E C E I V E (336)753-6780/ Fax (336) 753-1680
T ic6jt ER Far:9'-jZOt' &v 1 tion/Improvement Pennit Authorization To Construct(ATC) ❑ Both
T of Application: ❑Ne stem ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IMPORTANT*** THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed R5 RuXer LLG. Contact Person 6redc�'ta vl_ A nderzllcm
Billing Address SOZ #c r ' Home Phone
City/State/ZIP 6re
C,An tj bewA /VL 0 Z7 O 9 Business Phone 33(D -SW -&(r9`% X30&
Name on Permit/ATC if Different than Above 9 re�chen ®rs pa rlcek horyeGS .G
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flaaged Cl-- X f -
NOTE: A survey plat or site plan must accompany this application. Included: D Siite Plan GlKat(to scale)
(Permit is valid for 60 months with site plan, no expiration with complete plat.)
Owner's Name q 3 eAA r LLL Phone Number336 Sy/
Owner's AddressiC. r• ,` City/State/Zip SCeGVK !rl 77Y -CQ
Property Address 10 e City Oa e_ t
Lot Size 3Y, 5M 54 Tax PIN# 31 0ACCA'
Subdivision Name(if applicable) /VAectdol �1, _Section/Lot# 7—
Directions To Site:
If the answer to any of the following questions is "yes", supporting documentatio must be attached.
Are there any existing wastewater systems on the site? ❑Yes (2o
Does the site contain jurisdictional wetlands? F] Yes E -Ko
Are there any easements or right-of-ways on the'site? Comes ❑No
Is the site subject to approval by another public agency? ❑Yes
Will wastewater other than domestic sewage be generated? []Yes ko
TF RT4Z1D1 '.Nf P RTT T. 01 TT TNF RCIX RFT .CIW
# People yy- vy - yL v# Bedroomsv - 3 _ # Bathrooms Z Garden Tub/Whirlpool EVres ❑No
Basement: ❑Yes [ o 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: ❑-Conventional ❑Accepted ❑Innovative []Alternative ❑Other
Water Supply Type: ❑ County/City Water ❑ New Well []Existing Well Ch'Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes rv,o
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-aad rules. I un to d that I am responsible for the proper identification and labeling of property lines and corners and
locating an or st�gg the house/ci 'ty location, proposed well location and the location of any other amenities.
Property owner's or own le 1 repr&en ative signature Site Revisit Charge
Date(s):
9 - l es r d Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No
Revised 11/06
�
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Account
Invoice #
M
sEmAc
FRONT: 30' BEA UCHAMP ROAD (6o' R/W PUBLIC)
SIDE: 15' STREET SIDE: 25' S88°51 ' 56"E 127.77'
REAR: 30'
F-- — — —
W
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0
38.1'
� I
15.25'
13.33' g
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N
PROPOSED
2.00' RESIDENCE
22.08'
N
63' 13.17
0.751 '
22. '
— SETBACK
22.25'
16.83'
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zu
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\tza
\
10' UTILITY EASEMENT
N890 15' 57" W 166.97'
MEADOW CREEK COURT
(50' R/W PUBLIC) PRELIMINARY
GRAPHIC SCALE
30 0 15 30 60
( IN FEET )
1 inch = 30 ft~
PLOT PLAN FOR:
RSP BUILDERS
LOT 28 OF MEADOWS EDGE, PHASE 2
P.B. 8 PG. 259
Fleming Engineering, Inc.
700 Carnegie Place Greensboro, NC 27409
Phone: 336.852.9797 .k Fax: 336.852.9766
NCBELS C-0950 DATE: 08-21-12
REF: PROJ\1831-01\dwg\LOT 28 MEADOWS EDGE.dwg
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ENVIRONMENTAL
DAVIE COONlY _
TION 1:011 SIM LVilLUilTION/IAII'ILUVL•AlL•N'f 1'L•li 111' & ATC
Davie County Health Department
LUiTonu107471 Ha,7&11 Section
P.O. Dox 848/210 Rospital Street
blocksville, NC 27028
(336) 751-8760
***XMPORTANT*** THIS APPLICATION CANNOT DE PROCESSED Ui1LESS ALL TILL REQUIRLD '
IIIFORMATION IS PROVIDED. Refer to tho INFORMA'T'ION DULLETIN for inntructioni.
Jade Associates II LLC Alan Jones
1. flame to be Dilled ' ContacL 11cruon
Mailing Address Post Office Box 4062 l:a,ne Phone
City/State/'LIP
4iinston-Salem' PJC 27115-4062 Dusincus 1'lwuc (336) 759-9688
_
2. llama on Permit/ATC if Different than Above
Hailing Address
7. Application For: M Site Evaluation
City/StaLC/Zip
❑ ImprovcmcnL Pel7uit/A1'C
❑ Doth
4. Syctem to Service: ® House ❑ Mobile Home ❑ DusincLn ❑ Industry ❑ OL -1,e:,; _ --
'r
5. Type system requested: lel Conventional ❑ conventional modified ❑ innovative
G. If Residence: II People 4 II Bedroom:; 4 It baLllroom,; 2.5
Dishwasher InGarbagc Disposal nilanhing Tiachino ❑Dascmcnt/PlulNbing ®Da::cmonL/Ilo Plumbing
7. If Dusiness/Industry /OL•hor: verify type
I1 People I) ;inl:n
N Commodes It Showers 0 Urinala II WaL•cr Cooluru
IF FOODSERVICE: 11 Seat's Estimated Water Usage (gallons par day) _.__
S. Type of water supply: 0 County/City ❑ Well ❑ Conununityw
9. Do you anticipate additions or Upallsiolls Uf the facility this systelil is ill(L'lyded lu serve? ❑ yes Kq No
lf)'CS, 11'1lat type?
***IMPORTI1tVY" CL1EN'rSdruSTCOAII'LETE'rIIE I(EQUII(L'D PR01'L•'I(TY INFORMATION RE'QUESTIi)
BEL0W. hither a PLAT orSITE PLAN r1IUSTBESUIMIMYEU by (be client lvilh 'I'll IS AI'I'LICA')1ON. I
1'ruperly Di11lcnsiulls:
Tax office 11IN: Il
See attached map
5871615955
Property Address: Road Nalllc Beauchamp Road
City/Zip Advance, 27006
If ill a Subdivision provide information, as fullolvs:
Nalllc: Proposed Ja.de Associates
Section: Bloch: Lot: 28
WRITE* UIRLCTIUNS (from 1lluclm'illc) lu
East on highway 158, turn right onto
Gun Club Road and proceed to the end of :..
the road, turn left -onto Beauchamp Road
and the site is located approximately Wo
miles down Beauchamp•Road on the right and
left side of the road. 3/8/04
Date home cor11crs !lagged:
This is to certify that the information provided is correct to the best of my lulovledge. I Understand that .1113' permil(s)
issued hcrcaftcir arc subject to suspcusion or rcvocatioll, If the site plans Ur ill(cllded use change, ur if (lie iufur111:1 ioU
submi((cd in this applic:!(ion is falsified ur changed. !, a/so, I tl/lerstulid that I «ill 1-cg1ullsible jot rill chctlSges hiclurrd,Jroul
this application. I, hereby, give consent to (he Authorized 11cprescatalive of the Davie Cuunly Ilpal(Il De ):n•(){cnl
(o cl:(cr upon above described pruperty located ill Davie County and shed by Jade Assoc! ates
to conduct all testing procedures as necessary to dcternliue the site Suitability.
DA'11 3/15/04
SICNA'I'U1tE
TIIIS AREA MAY BE USED FOR DRAWING 'YOUR SITZ; PLAN (hlclude all of the 1'ullowillg: Existing and prupused
property lines and dimensions, structures, setbacl(s, and septic locations).
Site Rcvisit Charge
Date(s):
Clicut Notification Date:
EMS:
Sign given A n",
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003105 Tax PIN/EH #: 5871-61-5955.28
Billed To: Jade Associates II, LLC Subdivision Info: Prop. Jade Assoc. Lot # 28
Reference Name: Location/Address: Beauchamp Rd -27006
Proposed Facility: Residence Property Size: see map Date Evaluated:
Water Supply: On -Site Well Community
Evaluation By: Auger Boring Pit
Public
Cut
FACTORS
2 3 4 5 6 7
Landscape position
Slope %
-5110
0
HORIZON I DEPTH
0115
Texture group
Consistence
P15V .
Structure
L
Mineralogy'
1
`
HORIZON II DEPTH
Texture groupl�
}.
•CL .�
Consistence
(=
t
Structure
cAsic
Mineralogy
is
HORIZON III DEPTH
- Z
'JL
Texture group
•
5'k_L
Consistence
Fr SS
Structure
5gl
Mineralogy'
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
' a
SITE CLASSIFICATION: f
LONG-TERM ACCEPTANCE RATE: 3 ^�
REMARKS:t/►"��',IJ�
LEGEND
Landscape Position
EVALUATION BY:
OTHER(S) PRESENT:
(T- ,-, H4
—�>
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
Moist
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)