117 Meadow Creek Court Lot 33DAVIE 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 PIN: EH #: E8160A0033
Billed To: RS Parker Homes, LLC Subdivision Info: Meadows Edge Lot # 33
Reference Name: LocationiAddress: 117 Meadow Creek Court -27006
Proposed Facility: Residental Property Size: .72 Ac r,
ATC Number: 6022La
�
**NOTE** The issuance of this Operation Permit shall indicate the system described on. TC hasbeen mstali-ed�
in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disp-osal�ystet�i,
but shall in NO WAY'be taken as a guarantee that the system will function satisfactorily for any given period of
time.
System Type:_ C �a Manufacture rs f Tank Date 3T/D Tank Size / 0 00
Pump Tank SEW Bedrooms: tl
-System Installed By: Amyx 1 �'d1V1�0 t.� Installer# Date' � 6/ 3
GPS Coordinate:
m
Environmental Health Specialist
DCHD 11/06 (Revised)
/21
Date: 6
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 PINiEH #: E8160A0033
Billed To: RS Parker Homes, LLC Subdivision Info: Meadows Edge Lot # 33
Reference Name: Location/Address: 117 Meadow Creek Court -27006
Proposed Facility: Residental Property Size: .72 Ac
ATC Number: 6022
Site Type: VNew ❑Repair ❑Expansion
**NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental
Health Section prior t9 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 5 # People Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size- D2- Type of Water Supply: idCounty/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow (GPD) t4g(LTank Size /MO GAL. Pump Tank GAL.
Trench Width Max. Trench Depth_ Rock Depth Linear Ft.S�a
Site Modifications/Conditions/Other: Red uG bh
Contact the Davie County Environmental Health Section for final inspection of this system between
R-Ifi _ Q-1na m nn the slaw of inetallatinn TPlPnhnnP f! liiFl741_R7F0_ a�?14�
��
Environmental Health
DCHD 11/06 (Revis&
Date: ��
SETBACKS:
FRONT: 30'
SIDE: 15'
STREET SIDE: 25'
REAR: 30' —�
N89014'57" W
214.96'
c
33
o�
p^^r
50.83'
co
N
(I1
W
Cn PROPOSED
co RESIDENCE
2.00'
N
v
rn 13.17' w
cl
36.38'
16.83' ( G' 22.83'
SET3ACR
am /
5W N66°53'27"E
_10' UTILITY EASEMENT _ CH=41.23'
�—
S89° 15' S7"E RAD= 50.00'
79.47' PRELIMINARY
N66°38'21 "E PLOT PLAN FOR:
mEADOW CREEK COURT CH=20.41' RSP BUILDERS
(50' RIW PUBLIC) RAD=25.00' LOT 33 OF MEADOWS EDGE, PHASE 2
P.B. 8 PG. 259
GRAPHIC SCALE
30 0 15 30 60 Fleming Engineering, Inc.
700 Carnegie Place Greensboro, NC 27409
( IN FEET) . Phone: 336.852.9797 :, Fax: 336.852.9766
1 inch = 30 ft. NCBELS C-0950 DATE: 01-07-2013
REF: PROJ\1831-01\dwg\LOT 2D ... MtAUvwS tuut.al
Reference Name:
Proposed Facility: Residental
**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: gNew ❑Repair ❑Expansion Permit Valid for: 45 Years ❑,No Expiration
Residential Specifications: # Bedrooms # Bathrooms o)'.S # People Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD). :c'I� Type of Water Supply: County/City ❑Well ❑Community Well
Site Modifications/Permit Conditions:
e
i
Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
t
(336)753-6780 / Fax (336)753-1680
IMPROVEMENT PERMIT
Account #:
990005949
Tax PIN/EH #:
E816OA0033
Billed To:
RS Parker Homes, LLC
Subdivision Info:
Meadows Edge Lot # 33
Address:
502 Hickory Ridge Drive
Location/Address:
117 Meadow;�K, �T 27006
City:
Greensboro,
Property Size:
.72 Ac
Reference Name:
Proposed Facility: Residental
**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: gNew ❑Repair ❑Expansion Permit Valid for: 45 Years ❑,No Expiration
Residential Specifications: # Bedrooms # Bathrooms o)'.S # People Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD). :c'I� Type of Water Supply: County/City ❑Well ❑Community Well
Site Modifications/Permit Conditions:
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC
Davie County Environmental Health,
Z5' I P P.O. Boz 848/210 Hospital Street
`"'"Mocksville, NC 27028
�, i;l �• �� p
.(336)753-6780/ Fax (336)753-1680 / q
A 1 iati_o_n Fo);v ivation/Improvement Permit ❑Authorization To Constructt �(AT�C)7---
a� P i plicNew System ❑Repair to Existing System ❑Exoansion/Modification of Existing System or Facility
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSEDUNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name POLA 16 L LC-- Contact Person 6r A4&1<A0V\.--
Address
iej r i r, 33G -8 `i� -G e 9 9 X3 C)G
City/State/ZIP (,N!r C� Z % O� Business Phone 3 3 G ' z6- 7 - 5 S l Z
Email
Name on ermit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERIN 1N
NOTE:. A survey I
(Permit is
Owner's Name' '
Owner's Address
11UN
*Date House/Facility Comers
or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
I for 60 months with site plan, no expiration with complete plat.)
Property Address / % L
Lot Size IV --
Subdivision Name(if applicable
DirectionsTo Siie:
Phone Number
City/State/Zip,
ZSIWADo33
Section/Lot#
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
Does the site contain jurisdictional wetlands?
_Yes
Are there any easements or right-of-ways on the site?
Yes Zo
Is the site subject to approval by another public agency?
_Yes
Will wastewater other than domestic sewage be generated?
_ Yes -filo
TF RF,STDF,NCF FTT,T. OT JT THF, BOX BELOW
# People L — # Bedrooms # Bathrooms Z 5 Garden Tub/Whirlpool es ❑No
Basement: ❑Yes RKo- Basement Plumbing: ❑Yes C•�
TF NON -RESIDENCE, FTT,T, OTJT 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: onventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: County/City Water ❑ New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Pggo
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 He:Wth Department to con�er'
cessary inspections to determine compliance with applicable laws and rules.
I understand t res onsilyje for the p pntification and labeling of property lines and comers and locating and flagging
or staking /fac' ' to on, pr os l location and the location of any other amenities.
� Site Revisit Charge
Property owner's or owner's legal representative signature
Date(s):
Client Notification Date:
Date EHS:
Sign given ❑ Yes ❑No Account # -6q91?-
Revised
q `/Revised 11/06 Invoice # b q
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• _ DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
SoiVSite Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003105 Tax PIN/EH #: 5871-61-5955.33
Billed To: Jade Associates II, LLC Subdivision Info: Prop. Jade Assoc. Lot # 33
Reference Name: Location/Address: Beauchamp Rd -27006
Proposed Facility: Residence Property Size: see map Date Evaluated: - q [Z�
Water Supply: On -Site Well
Community
Public
Evaluation By: Auger Boring Pit Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
Slope %
`1 �
0
HORIZON I DEPTH
—10
Texture group
(1-4—
Consistence
Structure
rk
Mineralogy1
HORIZON II DEPTH
- 35
14 -15LP
Texture grou
; C
7 i ..X
Consistence
S$
Structure
Mineralogy
HORIZON III DEPTH
5
Texture grou
' L
' C L
Consistence
Prss NY I
Ara ov
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
p
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
LEGEND
Landscape Position
EVALUATION BY:�"`
OTHER(S) PRESENT:
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)
rD UE
ENVIRCNtiSEt1TAL HEALTH
p Vii
My
ON 1011 SITE- L"VALUATION/IA111II0VUII1-N'r 1'GG111 , & tiTC
Davie County Health Department
EnYiroi1n1enta/Hea/t/1 Section
P.O. Dox 848/210 HoDpiLal StrecL
Nocksville, NC 27020
(336)751-0760
* * *IMPORTANT* * * THIS APPLICATION CANNOT DE PROCESSED UIILESS ALL 11'IIE REQUIRLD
I1IFORI4ATION IS PROVIDED. Refer Lo L•ho INFORFIATION BULLETIN for inSLI:uCt:'iol'IJ .
1. !lame to be Billed Jade Associates II, LLC Contact Alam Jones
L' !'croon
Hailing Address . Post Office Box 4062 Ilome 1'hute ___•-•_-.._.
City/:,talc/'LIP
Winston-Salem' llusinuss 1'lluiw NC 27115-4062 (336) 759-9688
2. llama on Permit/ATC if Different than Above
Hailing Address
Ci L'y/StaLe/Zip
J. Application For: ® Site Evaluation ❑ ImprovcuienL Pel-llliL/ATC 0 Doth
4. 5yctem to Service: ® House ❑ I•Iobile Home ❑ Duidnesa ❑ Industry ❑ OL•llcr
ti.
5. Type system requested: M Conventional ❑ conventional modified ❑ innovaL•ive
6. If Residence: It People 4 II Bedrooms 4 II Datllroom;, 2 1. .5
tDiahwasher InGarbage Disposal KlWashing Machine I113a!;C1aCnL/I'lwnbinq ❑Ua-eulcnL/110 plumbing
7. If Dusinenn/Industry /Other: verify type II leol>lc It inks
9 Commodes 0 Showers 11 Urinalu II Wa Car CoolurD
IF FOODSERVICE: It SeaLa Estimated water USagc (gallons par day) _
8. Type of water supply: 1� County/City . ❑ well ❑ ColluuuliitylhS
9. Do you anticipate additions or cxp:Ulsiolls Urllle f:ll'llity this systelll i5 ill(CIIdcd tU 5el•1'e? ❑ Yes m No
Iryes, what type?
*R1411�OICI/I%Y[ k** CLIEN'rS,lrusrcau!'.LEr1:'rllE REQUIRED P)col'E C INFORMATION RLQUESTED
JELO1V. lather i PLAT orSITE PLAN AIUSTBESUIt,1117TEU by clic client nitll'I'I11S Al'I'LtC,I'I'ION.
1'ruperty Dimensions:
'1':lz Office 11IN: 11
See attached map
5871615955
Properly Address: Road Nallle Beauchamp Road
City/'Lip Advance, 27006
If ill a SUbdiyisioll provide iul'U111136on, as fullUlvs:
Nalllc: Proposed Jade Associates
Sectiou: Block: Lot: 33
Ww'rL•• llUtLCTIONS (I'rulu Aludin-ille) lu I'li1)1'liltTV:
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 too
i,iiles down Beaucharap Road on the right and
left side of the road. 3/8/04
Date polus corners 1labged:
This is to certify that the iufornlation provided is correct to the best ol•luy hIIO1VICdbe. 1 ullders(and that :1113-
issued
ulyissued hcrcafler are subject to Suspension or revocation, if the site pians UI• !!!tended n5C ch:nlge, ur if (he infor111.16uu
submitted ill this applica(ioll is f:dsilicd ul- cllallged. I, rl/So, 1111i/elstwu/ that 1 rurl reglUltsible jul. a// char es illcill.n.dProal
this lipplicatiull. I, hereby, give conscu(to (Ile Authorized Representative of the 1):I1viu CuIll, tl' 11c:11tit De ,: Hu ell!
to enter upon above described properly located ill Davie County and un•rled by Jade Ass'oci ates I , �LG
(u conduct ali testillg procedures 15 necesS:ll'y to deterinine the site suitability.
3/15/04
DATL SIGNATURE 1 r:�(�
.,
TIIIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of tllc fullmin6: Existing and prupused
property lines and diniensions, structures, se(backs, and septic IOCati0115).
Si(c Revisit Charge
D:llc(S):
Clicut Notification Dille:
EIIS:
Sign givell Arrn,inf Nn