128 Meadow Brook Court Lot 37DAVIE COUNTY ENVIRONMENTAL HEALTH
1 P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 /Fax # (336)753-1680
j
OPERATION PERMIT
Account #: 990005949 Tax PIRIEH #: E816OA0037
Billed To: RS Parker Homes, LLC Subdivision Info: Meadows Edge Lot # 37
Reference Nape: LocationiAddress: 128 Meadow Brook Ct.-27006
Proposed Facility: Residence Property Size: .68 Acre
ATC Number: 6023
**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 functionsatisfactorily for any given period of
time.
System ,Type: S.T. Manufacturer Tank DateAp Mh Tank Sizej_260
Pump Tank Size ' m� Bedrooms: �{
System Installed By: �ian�LTi(A1�Sfn�t Installer# Date: 520 26
GPS Coordinate:
tJ tA
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-------------
1• `Cr`ui' v'
1
Environmental Health Specialist Date:V_0q%2!
DCHD 1 x/06 (Revised)
i
' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003105 Tax PIN/EH #: 5871-61-5955.37
Billed To: Jade Associates II, LLC Subdivision Info: Prop. Jade Assoc. Lot # 37
Reference Name: Location/Address: Beauchamp Rd -27006
Proposed Facility: Residence Property Size: see map Date Evaluated:
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
L'
Slope %
HORIZON I DEPTH
O
-
Texture group
Consistence
Structure
1L
Mineralogy
HORIZON II DEPTH
4 Q
-
Texture group•C
Gk$
Consistence
Structure
iG
Mineralogy
HORIZON III DEPTH
- Z
Texture group
Consistence
�l
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: 0 -
REMARKS:
•REMARKS:
Jw,Q La R,
EVALUATION BY:
OTHER(S) PRESENT:
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 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 - gaVday/ft2
DCHD 05/99 (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 M 990005949 Tax PIN/EH #: E816OA0037
Billed To: RS Parker Homes, LLC SubdivisionInfo: Meadows Edge Lot # 37
Reference Name: Location/Address: 128 Meadow.;$;MALR-27006
Proposed Facility: Residence Propefty Size: .68 Acre
ATC Number: 6023
Site Type: XNew ❑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 A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat
or the intended use change.
Residential Specifications: # Bedrooms 4 # Bathrooms_a,� # People Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People 1 # Seats
Square Footage(or Dimensions of Facility)
Lot Size o(A(_ Type of Water Supply: ❑County/City ❑Well El Community Well
System Specifications: Design Wastewater Flow (GPD) qkO Tank Sizebw GAL. Pump Tank /61Z GAL.
Trench Width��` Max. Trench Depth 2 Rock DepthLV� Linear Ft y 075"!0
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 in tallation. Telephone # (336)751-8760.
t
. -A
;91
aux
Environmental Health Specialist ! 0,,J Date: a?00
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
IMPROVEMENT PERMIT
Account #: 990005949 Tax PIN/EH #: E816OA0037
Billed To: RS Parker Homes, LLC Subdivision Info: Meadows Edge Lot # 37
Address: 502 Hickory Ridge Drive Location/Address: 128 Meadow Brook Ct.-27006
City: Greensboro, Property Size: .68 Acre
Reference Name:
Propond Facility Relsidence
NOTE* 'This mprovement 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: f4New ❑Repair ❑Expansion Permit Valid for: A-5 Years ❑No Expiration
Residential Specifications: # Bedrooms I- # Bathrooms 2•S # People 14 Basement❑ Basement plumbing
Non -Residential Specifications: Facility Type # People # Seats_
Square Footage(or Dimensions of Facility)
Design Flow(GPD): q90 Type of Water Supply: gCounty/City ❑Well ❑Community Well
Site Modifications/Permit Conditions:
S stem Type _LTAR
Initial ce S
Repair 05510i
i.p. I I-06
r
SETBACKS:
FRONT: 30'
SIDE: 15'
STREET SIDE: 25'
REAR: 30'
MEADOW CREEK COURT
1(50' RIW PUBLIC)
GRAPHIC SCALE
( IN FEET )
1 inch = 40 ft.
PRELIMINARY
PLOT PLAN FOR:
RS PARKER HOMES
LOT 37 OF MEADOWS EDGE, PHASE 2
P.E. 8 PG. 259
Fleming Engineering, Inc.
700 Carnegie Place Greensboro, NC 27409
Phone: 336.852-9797 . Fax: 336-852.9766
NCBELS C-0950 DATE: 01-03-13
REF: PROJ\1831-01\dwg\LOT 37 MEADOWS EDGE.dwg
Davie County, NC - GoMaps Advanced
lit
Page 1 of 1
500
280 ft Latitude; 35158' '27,S -O` Longitude; -80126' 16 43'
�1
http://maps.roktech.net/davie_gomaps/index.html 1/31/2013
0
APPLICATION FOR SITE EVALUATION/IMPROVFi4MENT PERMIT &ATC
Davie County Environmental Icsl
P.O. Box 848/210 Hospital Stroft
Mocksville, NC 270281 c` 'a'
(336)753-6780/ Fax (336)753-11
Application For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct (AToth
Type of Application: ❑New System ❑Repair to Existing System ❑Exvansion/Modification of Existing System or Facility
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name R5 Pculcc Contact Person ricls
Address Z V Wt-c-L-Arr HeifieP4au 3 - -L/ - 30
City/State/ZIP z 7 Business Phone 336 - efCo 7-8 8 / Z
Email re r , I
Name on Pe ATC if Different khan Above
Mailing Address ity/State/Zip
INFORMATION
*Date House/Facility Comers
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' ' L Phone Number 3:
Owner's Address _ Ci /State/ZiD
Property Address
Lot Size Tax PIN#
Subdivision Name(if applicable) Aden
Directions To Site:
V -GG
Ell, OA003 77
-, &8'4L7r,&
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 e
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
Yes dq
Will wastewater other than domestic sewage be generated?
�No
TF RESIDF,NCE FIT T, OT IT THF, BOX BFI,OW
# People # Bedrooms # Bathrgper6s Garden Tub/Whirlpool es ❑No
Basement: ❑Yes Nfio Basement Plumbing: ❑Yes o
IF NON -RESIDENCE Fff I, 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:
❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type:ounty/City Water ❑ New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Ch
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 C unty Health Department to duct necessary inspections to determine compliance with applicable laws and rules.
I understan sp sible for a oper identification and labeling of property lines and comers and locating and flagging
or stakin e/ cil' locatio oposed well location and the location of any other amenities.
Property owner's or owner's legal representative signature Site Revisit Charge
Date(s):
Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account # 5-"/-G
Revised 11/06 Invoice # i� 2'3
l
D
�r1AR 1 5 2D04
EN aooiA 1mutn—rf,
TION I:O1( SITE- [VALUATION/lAll'aomi1 NT IIC-N1111- & ATC
Davie County Health Department
EnYironi»enta/Hea/t/1 Secti0l]
P.O. Dox 848/210 Hospital Street
Mocksville, NC 270213
(336)751-0760
***IMPORTANT*** THIS APPLICATION CANNOT DE PROCESSED WILLSS ALL T11B REQUIRLD
INFORMATION IS PROVIDED. Refor to tho INFORMATION BULLETIN for i11zL:1ucti0rl0.
9. Do you anticipate additions or C\I):UISiolis of the facility (his systclll is ill(CI1(IC(I lu Serve? ❑ Yes m No
If )'es, what type?
'**lAll'OltlitNT''** CL1I:NTSBIUST COAIPLGTL•'"rill: /(L'QU!/(L•'U !'1101'lafl'1' lIV1�0llf1lr1'I'ION Il�Ll11:S'I'I;U -__.I
(3CL011'. 1silllcra PLAT orSITE PLAN HUSTBESUHH1TIED by (lie clicoI .wilh TIIIS AI'll I,ICATION.
ProperO, Dilncllsiuns: See attached map lVIIITL DIRLCI'IONS (fruul Illudin-ille) lu 1'ItUI'littTY:
Tax Office 11IN: # 5871615955 East on Iii ghway 158, turn right onto
Prol)crty Address: Road Nallic Beauchamp Road Glln Club Road and proceed to the end of
City/Zip Advance, 27006 the road, turn left -onto Beauchamp Road
If in a Subdivision provide infurnla(ion, as follows:
Nalllc: Proposed Jade Associates
Section: Bloch: Lot: 37
and the site is located approximately too
miles down Beauchamp Road on the right and
left side of the road. 3/8/04
Date Monte corners Nagged:
This is to certify that ((!e information provided is correct to the best oflny lcuowledl;e. I understand that :uly pe•luil(s)
issued hereafter are subjcct to suspcnsi011 or revocation, if the site plans or intended use ch:ulge, or if (lie iufu'nl:16011
subnli(ted in (bis application is falsified ur changed. I, also, understand that I am ra5pulrsible fur al/ chwjS cs hicurred i•um
thisapplicatun. I, hereby, give consent to (Ile Au(horizcd Represcuta(ivc of the Devic Cuuuty IIpallh De m1,111 cu
to colcr upon above described pruperty located in Davie County and Owned by Jade Assoc1 ates � I , tL�
to conduct all testing procedures as ucccssary to de(ernline (lie site suitability.
3/15/04 4
llA'I'L SIGNATURE
THIS ARCA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of [lie fullowhig: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Itcvisil Charge
lla(c(s):
Client Nolificaliun Date:
EI -IS:
Sigel given Arrnnnl N.,
Jade Associates
II, LLC Alert Jones
1.
Name to be Billed
Contract• Person
Post Office Box
4062
Mailing Address -
non(c Phone
Kinston -Salem,
PJC 27115-4062 (336) 759-9688
City/state/GIP
lluslncus PUuuo
2.
Ramo on Permit/ATC if Different than Above
Hailing Address
City/Stale/Zip
3.
Application For: 19 Site Evaluation
❑ Improvement Pcrwit/A1'C ❑ UuLli
!.
system to service: ® House ❑ Mobile home ❑ Dusincsn ❑ Industry ❑ OLltcr
S.
Type system requested: C� Conventional
❑ conventional modified ❑ inilova Livc
4
4 2.5
6.
If Residence: 11 People
11 Dedrooms II DaLllroonul,
tDinhwasher I'JGarbage Disposal nklashing
Dlachina M13at; cmonL/11Iu l.ling ❑UacemenL/Ho 1'lumbinr!
7.
If Dusiness/Industry /OLhor: verify type
1! Pcople I! ittl:s
N Commodes II Showers
it Urinala 11 WaLcr Coolcrs
IF FOODSERVICE: 0 Seats
Estimated Water Usage Gallons per day)
S.
Typo of watcr supply: I� County/City
❑ Well ❑ Conunuliity
9. Do you anticipate additions or C\I):UISiolis of the facility (his systclll is ill(CI1(IC(I lu Serve? ❑ Yes m No
If )'es, what type?
'**lAll'OltlitNT''** CL1I:NTSBIUST COAIPLGTL•'"rill: /(L'QU!/(L•'U !'1101'lafl'1' lIV1�0llf1lr1'I'ION Il�Ll11:S'I'I;U -__.I
(3CL011'. 1silllcra PLAT orSITE PLAN HUSTBESUHH1TIED by (lie clicoI .wilh TIIIS AI'll I,ICATION.
ProperO, Dilncllsiuns: See attached map lVIIITL DIRLCI'IONS (fruul Illudin-ille) lu 1'ItUI'littTY:
Tax Office 11IN: # 5871615955 East on Iii ghway 158, turn right onto
Prol)crty Address: Road Nallic Beauchamp Road Glln Club Road and proceed to the end of
City/Zip Advance, 27006 the road, turn left -onto Beauchamp Road
If in a Subdivision provide infurnla(ion, as follows:
Nalllc: Proposed Jade Associates
Section: Bloch: Lot: 37
and the site is located approximately too
miles down Beauchamp Road on the right and
left side of the road. 3/8/04
Date Monte corners Nagged:
This is to certify that ((!e information provided is correct to the best oflny lcuowledl;e. I understand that :uly pe•luil(s)
issued hereafter are subjcct to suspcnsi011 or revocation, if the site plans or intended use ch:ulge, or if (lie iufu'nl:16011
subnli(ted in (bis application is falsified ur changed. I, also, understand that I am ra5pulrsible fur al/ chwjS cs hicurred i•um
thisapplicatun. I, hereby, give consent to (Ile Au(horizcd Represcuta(ivc of the Devic Cuuuty IIpallh De m1,111 cu
to colcr upon above described pruperty located in Davie County and Owned by Jade Assoc1 ates � I , tL�
to conduct all testing procedures as ucccssary to de(ernline (lie site suitability.
3/15/04 4
llA'I'L SIGNATURE
THIS ARCA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of [lie fullowhig: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Itcvisil Charge
lla(c(s):
Client Nolificaliun Date:
EI -IS:
Sigel given Arrnnnl N.,
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003105 Tax PIN/EH #: 5871-61-5955.37
Billed To: Jade Associates II, LLC Subdivision Info: Prop. Jade Assoc. Lot # 37
Reference Name: Location/Address: Beauchamp Rd -27006
Proposed Facility: Residence Property Size: see map Date Evaluated: Lf -S -1L C1
Water Supply:
On -Site Well
Community
Public
Evaluation By:
Auger Boring
Pit ✓
Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
t�_
Slope %
to 7V
HORIZON I DEPTH
0 —77 -
Texture group
Consistence
• j
Structure
1L
Mineralogy(;
HORIZON II DEPTH
Texture group•C
G�
Consistence
Structure
Y
Mineralogy
/:1 till
HORIZON III DEPTH
- l
Texture group
Consistence
'j
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
f 11-5
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS: � OJ LIV. tk1
EVALUATION BY: ',,)
OTHER(S) PRESENT:
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 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)