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127 Meadow Brook Court Lot 39• DAVIE COUNTY ENVIRONMENTAL HEALTH • • P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 OPERATION PERMIT Account #: 990004197 Billed To: Harrell Construction Remodeling, Inc. Reference Name: Proposed Facility: Residence ATC Number: 4562 Tax PIN/EH #: 5871-52-3416.39 Subdivision Info: Meadows Edge II Lot # 39 Location/Address: 127 Meadow Brook Ct.-27006 Property Size: 0.97 acre **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. �t ' System Type: S.T. Manufacturer Tank Date 17— Tank Size t' -C> Pump Tank Size System Installed By:�—"" E H. Spe94 Qoej� q S-11, 16- DCHD 11/06 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ` Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003105 Tax PIN/EH #: 5871-61-5955.39 Billed To: Jade Associates II, LLC Subdivision Info: Prop. Jade Assoc. Lot # 39 Reference Name: Location/Address: Beauchamp Rd -27006 Proposed Facility: Residence Property Size: see map Date Evaluated: Water Supply: Evaluation By On -Site Well Auger Boring Community_ Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH -2 Texture group C CL_ Consistence ,' S is Structure Mineralogy; HORIZON II DEPTH o- 2 Texture group C_+i Consistence SS's Structure 5 L Mineralogy HORIZON III DEPTH �D • 53 $ - O Texture group (SL :2_ Consistence Structure Mineralogy1. HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE , SITE CLASSIFICATION: PS EVALUATION BY:�"� LONG-TERM ACCEPTANCE RATE: �•�J 0 '� OTHER(S) PRESENT: REMARKS: C V� LEGEND Landscaae 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 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) J /,''cD DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751.8760 Fax #(336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990004197 Tax PIN/EH #: 5871-52-3416.39 Billed To: Harrell Construction Remodeling, Inc. Reference Name: Proposed Facility: Residence ATC Number: 4562 Subdivision Info: Meadows Edge II Lot # 39 Location/Address: 127 Meadow Brook Ct.-27006 Property Size: 0.97 acre **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 FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. il J ' Residential Specification: Building Type , I 0 #People #Bedrooms `t #Baths 3 Basement w/Plumbing: T Basement/No Plumbing Commercial Specification: Facility Type #People #People/Shift #Seats Lot Size DD q- Water Supply Com,, Design Wastewater Flow (GPD) Ned Site: New /Repair— System RepairSystem Specifications: Tank Size I COO GAL. Pump Tank _ GAL. Trench Width W Trench Depth 3q It Rock DepthhVI _ Linear Ft.q(521 \ Other: Required Site Modifications/Conditions:rn_j (�u— AA CM � � . � � DL� 4e ? /01 O1� Contact the Davie County Environmental Health Section for finat inspection of this system befween 8:30 — 9:30a.m, on the day, of installation. Telephone # (336)751-8760. Environmental Lv DCHD 11/06 (Revised) SITE FLAN • Harrell Construction & Remodeling, Inc. Harrell Construction & Remodeling, Inc. e ` 17 2 2006 ; MEIJAL HEALTH uav;� ceurdrr Application For: ❑ Site Eva ua i ITE EVALUATION/IMPROVEMENT PERMIT & ATC lavie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 Permit 216thorization To Construct(ATC) ❑ Both ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED I INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION kAL Name to be Billed la-•,��1� G,�sTa,.`T;.� (4-�^^nontact Person lir►, i�0.�r ill �q�` Billing Address ? . a C. Home Phone 3 3 c c — C'i V, City/State/ZIP ce�-W ra n.e.-� S t.1 C 7-7 a %Z Business Phone -7-, a - Z, 5"t- Name zName on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION NOTE: A survey plat or site plan must accompany this application. (Permit is valid for 60 months with site plan, no expiration with complete plat.) Street Address Iz-t P\emno.a City&t J, Jeg Tax PIN# SS 71 —$z. - 34t to Subdivision Name M£,,1,gwS Edi - Section/Lot# 3q Lot Size o. -j-7 t,en,.,)_ Directions To Site: i rc ,-. Q �U'ktv--d ori rte- ,4I 4 " Date House/Facility Corners Flagged I -z. I z. -a I " c 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? Dyes ❑X'o Does the site contain jurisdictional wetlands? ❑Yes Di16 Are there any easements or right-of-ways on the site? ❑Yes J:�No Is the site subject to approval by another public agency? Dyes HNo Will wastewater other than domestic sewage be generated? Dyes [31-10 IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms �_ # Bathrooms 511-t- Garden Tub/Whirlpool es ❑No Basement: DYes ❑ < 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: 21Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: 0-County/City Water 0 New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 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 understand that I am responsible for all charges incurred from this application. 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 on the above described property located in Davie County and owned by Vn,r,-.,,tl, �r s-tttia �.^ i� ( �•W—� �^� 1•-� . r-- Site Revisit Charge Property o er's or owner's I al representative signature Date(s): L 28 F�° Client Notification Date: Date 1 EHS: 0, Sign given Dyes ❑No ) Account #T/7/ Revised 2/06 Invoice # D26AVIECOUNly LICATION 1:011 S171 L•VALUATIONJIMP11UVEMENT 1'E11B11T & ATC Davie County Health Department Ei1Yironmenta/Hea/t// SectionP.O. Dox 848/210 IIospital Strect Mocksville, NC 27028 (33G)751-8760 * * *IMPORTANT * * * THIS APPLICATION CANNOT BE PROCESSED UIILLSS ALL THE REQUII:ED I INFORMATION IS PROVIDED. Refor to the INFORMATION BULLETIN for inntrucL'ion:l. Jade Associates II, LLC Alan Jones 1. 11=c to be Dilled Contract' Person Mailing Address •• Post Office Box 4062 Hone Phone Clty/State/'LIP Wllusiness Phu„c inston-Salem, t1C 27115-4062 (336) 759-9688 1. Nana on Permit/ATC if Different than Above Hailing Address 1. Application For: M Site Evaluation City/StaCc/Zip ❑ Improvement Peliiiit/ATC U ]loth 4. Syctcm to Service: E3 House ❑ lfobile Home ❑ Businc�ls ti S. Type system requested: n Conventional ❑ conventional modified 6. If Residence: II People 4 1) Dedroome 4 6Dishwaaher InGarbage Disposal Washing Machine ®Dasemont/Plumbing ❑ Industry ❑ OLllcr -- -- ❑ innova Live 7. If Dusiness/Industry /Other: verify type N Commodes 11 Showers it Urinals t! People II UaLhroall:) 2.5 1J1faccmenL/1do Plumbing II (Vater Cooler) IF FOODSERVICE: It SeaLD Estimated Water Usage (Uallono per day) 8. Type of water supply: 0 County/City ❑ Well ❑ Collunulii Ly 9. Do you anticipate additions or CXI)a11si011S of the f lCillty this S3'StCl1l is ill(CMIC(I to SCI'1'C'1 ❑ YCS Nu If yes, what 0 -pe? JA1I'UAJA1vl'"*° CLILNTS AIUSTC0A11'LETE'r11L 1U'QU11?ED P1tOnl(TY INFOltMATION ItISQUESTE'D BELOW. Cilller a PLAT or SITE PLAN 41UST11ESU114117TED by the client ,rilh'1'IIIS AI'PI,IC�1'I'ION. !'roperO' Dinlcnsiolls: See attached map )VIVI'L DIRL PIONS (fr(nH Alucksvllle) lo 1'Itt)VERTV: Tax Office PIN: fl 5871615955 East on Highway 158, turn right onto Property Address: Road Nallle Beauchamp Road City/Zip Advance, 27006 Gun Club Road and proceed to the end of the road, turn left -onto Beauchamp Road If ill a Subdivision provide information, as follows: and the site is located approximately two Nalllc: Proposed Jade Associates miles dorm Beauchamp Road on the right and left side of the road. Section: Block: Lot. Date home corners flagged: 3/8/04 C' -'l rte This is to certify that Elle information provided is correct to the best of my lulowledge. I understand that any peruli((s) issued hereafter arc subject to suspension or revoca(iall, if the site plalls or ill(crldcd use ch:ulgc, ur if (lie inl'u►'nla(iou submitted 111 Ellis appliCalioll is falsified ur changed. 1, also, understand that 1 «ut rrspurlsrblc fur all Charges ill Clu'!'('ll i'uul this appllcatiun. I, hereby, give consent to Elle Authorized Rcprescll(aliyc of (Ile Davie Cuunty I1calth De`): dlylll (o cuter upon above described prupc►'ty lucatcd iH Davie County atld ull'llcd I))' Jade Associates 4 LLC to cunducl all testing procedures as necessary to determine Elle site sui iO'. 3/15/04 DATESIGNATURE TIlIS ARCA MAYBE USED FOR DRAWING YOUR SITE PLAN (Include all of the fullolyhig: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site licvisil C11:n'ge llatc(s): Client Notification Date: ElIS: Sigel given '% Nf -