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129 Meadow Brook Court Lot 38DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990004019 Tax PIN/EH #: 5871-52-5235 Billed To: E.J. Hanes Construction Reference Name: Proposed Facility: Residence ATC Number: 4501 Subdivision Info: Meadows Edge Lot # 38 Location/Address: Beauchamp Rd -27006 Property Size: 1.50 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage ea nd Disposal Systems). THIS AUTHORIZATION FOR WASTEW CTI N S VALID I, R A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature Date: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate c has been installed in compliance Disposal Systems," but shall in given period of time. Lf'?- FLO u/ (ra� �5eVi I t S�TiC. Pr -z3io Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) 'ompletion shall indicate the system described on Improvement/Operation Permit th Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and WAY be taken as a guarantee that a syst will function satisfactorily for any F r 4111 AA C A — \%V cin � tl l at> Date: 1 I I DAVIE COUNTY HEALTH DEPARTMENT �- Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003105 Tax PIN/EH #: 5871-61-5955.38 Billed To: Jade Associates II, LLC Subdivision Info: Pro Jade Assoc. Lot # 38 Reference Name: Location/Address: Beauchamp Rd -27006 Proposed Facility: Residence Property Size: see map Date Evaluated: 5 J'q C/ Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit +� Public L-1- Cut / Cut FACTORS 1 3 4 5 6 7 Landscape position Slope % a HORIZON I DEPTH J Texture group Consistence Structure 1L Mineralogy.') HORIZON II DEPTH Texture group 5 i CIX Consistence Structure IL Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: l S LONG-TERM ACCEPTANCE RATE: O 3 J O EVALUATION BY: 11��%GH'�l�`7 OTHER(S) PRESENT: REMARKS: EC(,A''bMr� W -^_.j[ -14L f -U"^ tVrto--- Or— ;JNA PDT Co 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 Mineraloev 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) DAVIE COUNTY HEALTH DEPARTMENT • ' , , Environmental Health Section • P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990004019 Billed To: E.J. Hanes Construction Reference Name: Proposed Facility: Residence Tax PIN/EH M 5871-52-5235 Subdivision Info: Meadows Edge Lot # 38 Location/Address: Beauchamp Rd -27006 Property Size: 1.50 ATC Number: 4501 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Typ#People #Bedrooms"#Baths Z.`S Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 1 .�AL-R-::S Type Water SupplyDesign Wastewater Flow (GPD) Site: New 12'/ Repair ❑ 1 System Specifications: Tank SizeI� GAL. Pump Tank ICUDGAL. Trench Width 'l Rock Depth N - Linear Ft.-4W— Other: �EL-fro R4)&11 `yrA Sm m &(!�) , i Required Site Modifications/Conditions: �rJSTA1,L (r r,mg, I- 1, 1' IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** L J ©, /lffibX. tic; Environmental Heal Specialist's Signature: Mi til k" St" 40 DCHD 05/99 (Revised) mq Date: \ Cf/2z, flue 29 06 01:53p davie County envhealth 336 751 8786 APPLICATION FOP, SITE EVALUATION/11v[PROVEMENT PERMIT Davie County Health Department Environmental Health Section P.O. Box 8481210 Hospital Street Macksville, NC 27D28 (336)751-87601 Fax (336)751-8786 Application For. C Site Evaluation, Improvement Yertnit Authorization To Construct(ATC) III 'IMPORTANT' THIS APPUC'.TION CANNOT BE PROCESSED 1.,W= ALL OF 71 JE REQUIRED INFORMATION IS PROVIDED. R cfer to the WORMAT10N BL LEI7N for instructions. INrUKI K1,IUN Name to be Billed G. J • ontact Person 5 Billing Address _ Bome Phone City/StatelZII' .2--71Z7 Business Phone J t Name on Pc mit/ATC if Different titan Abovc. Mailing Address _ PROPERTY .INFORMATION P.2 SEP 1 9 2006 ENVIRONMENTAL HEALTH I)AVIE COUNTY NOTE: A sutae"lat or site plan nun-. accompany this application (Permit is valid far 60 months with site phn, no expiration witt1coptpletelat.) Street Address City - /"td AC�`Tax P 162 -.15 02- 1S Subdivision Name Section/Lot# Lot Size .- y' Directions To Site: w - Lxt &Pn Date HouselfacilityCotners.Flagged If the answer to any of the following gwxitions is `j es", supporting documentation must be attached.. Are there arty ousting wastewater systems on the site? IlYe lwo Does the site contain jurisdictional wetlands? DYG- Ate there any easemmtis or right-of-ways on the site? 11Yc: qtko is the site subject to approval by another public agency? 0Ye . �% Will wastewater other thaa dor--=dc sewage be generated? OYe% t�7o IF REST2!4Z FILL. OUT THE BOX BF W # People # Bedro)ms# Bathrooms Garden Tuh/Whirlpool- es ONo Basement Des Mo Bas;-rrentPlumbinl;: ElYes bNo IF NON -RESIDENCE FILL OUPl THE BOX BELOW Type of Facility/Bpsiness Total Square Foota,,e of Building_ # People # Sinks # Commodes _. # Showers - # Urinals Estimated Water Usage (gallons per day) _ .`_(Attach documentation of similar facility water consttinption) FOODSERVICE ONLY: # Seats Type system requested_Vtonventional QAccepted-OInnovative-OAhereative-tl0eimr--- Water Supply Type: )County/City Watt T 0 New Well 0Existing Well 0 Conz.,ity Well Do you anticipate additions oreapansior s of the facility this system is intcnde 3 to serve? O Yes XNo If yes, what type? This is to certify that the infomoation provided on this application is tare and correct to the best of my knowledge. I understand that any petnrit(s) or ATC(s) issued hereafter are subject to suspension or mvocatitm if tate site is altereti, the intended use oranges; a`r if-- the f--the information submitted in this application is falsified or changed I undersl vtd that! aar responsible for all charges incurred from this application. I hereby grant right of entry to the Authorked Repre=ttative of the Davie County Health Departracut to conduct necessary inspections to dere nix comp Tanta @ ap �iable lagN rru[e_f o above described property located in Davie County and owned by t,$:' deter t "` Site Revisit Chage Pro is or owner's egal reps es_ ntative signature Date(s):, ClientNotification Data. Date EHS' Sign given £lYes ONo Account # Revised 2/06 Invoice 0 ,9� 5594 _ t. t ho &��� Rei=_ QRS 15.57, �. �. N 79'42'45" f{� 44 229.93' Sr kp tp do 25 for dot sent 8.20' _ f l 1 tsee note 12> d i R. 9 Phase 1, Meadow! plat Book -8 0 143, ' PIN: 5871615', 4 cy 39)9 80 0.97 acres r-- 406' ciy hQ) 1 �Z_Cd Ca V� �o Ref . IRS, \ o /s 15.57' 22 7001,22,, z4 c�j �?0 37 .0 k, ell 0.69 acres i VEL 295.70 . _�° . � � fsee note l2) � � f;� �nsar7�'lerlt fQr LQ F� ,24 s dg �J �• em . r4 Q\O D �cS• pa PP Op 38 3 1/2" EI 1.50 acres IRS C3 Septic Eosement .o for Lot 36 -- 258.20F (see note 12) I `R� D , ENVIRONMENTAL HFALIH DAVIECAU_ f--.---' TION 1:011 SITE EV1ILUATION/Ihil'R0VL•.hll•N'I" I'L•1I11117' 11TC Davie County Health Department Enviroilinenta/Health Section P.O. Dox 848/210 Hospital Strect Mocksville, PTC 27020 (33G)751-07(10 * * *.WPOR TANT*** TItIS APPLICATION CANNOT DL PROCESSED U1ILLSS ALL TIM I LQUII -D IIIFOR4ATIOIT IS PROVIDED. Refer to the INFORMATION BULLETIN for insLrueLion!). if )'CS, What t)'llC?• '**!AI!'ORTi1NT*** CLILNTSA1USTCOilliLGTETllL 1U QUll(L•'U 1'1tOl'LICI'1' hYh01tl1IA'1'lON I(t?QUES'1.ED 8EL011'. Ei(It er a PLAT or SITZ PLAN AIUSTBE- SUMU/T-%GD by the dienI iriIIt TIIIS AI'I'LICATION. 1'ruprrly llinlcusiuns: See attached map 11'R1'f[s DIRECTIONS (frum Alucl;scille) lu I'ItUI'l:It'I'1': 'I':Iz Office PIN: 11 5871615955 East on Ili ghway 153, turn right onto I'rollcrty Address: Road Name Beauchamp Road Gun Club Road and proceed to the end of City/Zip Advance, 27006 the road, turn left -onto Beauchamp Road If ill a SUbdiVisi011 provide infurnlation, aS fullulvs: and the site is located approximately WO Milne: Proposed Jade Associates miles down Beauchamp Road on the right and left side of the road. Section: Block: Lot: 36 Date ►Ionic corners Nagged: 3/8/04 This is to certify that elle information provided is correct to the best of my lunoll•ledge. 1 understand that :1113' perulil(s) issued hereafter are subject to suspension or revocation, if the site plans ur intended use ciculge, or if the iufornlmiou submitted in this application is falsified ur changed. 1,, also, ander•stand that I ares respunsible fur• all charges incrn'r(vl fru«n flris ul)plicatiurl. I, hereby, give consent to the Authorized Representative of the 1):11'ic Cululty Ile:lltll Dell: rill n j to enter upon above described property located in Davie County and ull•lied by Jade Assoc1 ates 41 , ILC to conduct all testing procedures as necessary to determine the site suitability. 3/15/04 DATL S1CNA'fUlZli ( �/ T1i1S AREA MAYBE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and prolmed properly lines alld din1C11SiOlIS, s(ructures, setbacks, and septic locations). Site Revisit Charge ---- Client Notification Date: E1.1s: Slgll giycll Arrnnnl No 131 lD S Jade Associates II, LLC Alan Jones 1. !tune Co be Dillcd ConLacL Person Post Office Box 4062 nailing Address Home I'llutie llinston-Salem' NC 27115-4062 (336) 759-9688 City/State/'LIP I1UD1111.'DD phone 2. tlamo on Permit/ATC if Different than Above Nailing Address City/SLaLc/Zip J. Application For: ® Site Evaluationi ElImprovement PetmiL/ATC ❑ T1UL'Il 9. 5yctem to Service: ® House ❑ 1•Iobile Home ❑ 1ju,1.lic"o ❑ Indus try ❑ OLlter ti 5. Type sys•tcm requested: M Conventional ❑ conventional modified ❑ innovative 6. If Residence: II People 4 Il Bedrooms 4 II Isatlirootu:� 2.5 t Diahwasher 'L`1Garbage Disposal nViashing Dlachino MDascmcnl/Plumbing ❑1=*c111cl1L/Ilo I'lumbing 7. If Dunincas/Industry /Ocher: verify type 11 Pcoplc I Commodes 8 Showers II Urinalo II WaL'cr Cool CrD IF FOODSERVICE: ft Sea LD Estimated PlaLer Uoagc (gallons per day) 8. Type of water supply: IXI County/City ❑ wull ❑ ConununiL•y 9. Do you anticipate additions or C\p:Llsi011s of the facility this System is hitell(led to Sel'1'u? ❑ Yes 0CV No if )'CS, What t)'llC?• '**!AI!'ORTi1NT*** CLILNTSA1USTCOilliLGTETllL 1U QUll(L•'U 1'1tOl'LICI'1' hYh01tl1IA'1'lON I(t?QUES'1.ED 8EL011'. Ei(It er a PLAT or SITZ PLAN AIUSTBE- SUMU/T-%GD by the dienI iriIIt TIIIS AI'I'LICATION. 1'ruprrly llinlcusiuns: See attached map 11'R1'f[s DIRECTIONS (frum Alucl;scille) lu I'ItUI'l:It'I'1': 'I':Iz Office PIN: 11 5871615955 East on Ili ghway 153, turn right onto I'rollcrty Address: Road Name Beauchamp Road Gun Club Road and proceed to the end of City/Zip Advance, 27006 the road, turn left -onto Beauchamp Road If ill a SUbdiVisi011 provide infurnlation, aS fullulvs: and the site is located approximately WO Milne: Proposed Jade Associates miles down Beauchamp Road on the right and left side of the road. Section: Block: Lot: 36 Date ►Ionic corners Nagged: 3/8/04 This is to certify that elle information provided is correct to the best of my lunoll•ledge. 1 understand that :1113' perulil(s) issued hereafter are subject to suspension or revocation, if the site plans ur intended use ciculge, or if the iufornlmiou submitted in this application is falsified ur changed. 1,, also, ander•stand that I ares respunsible fur• all charges incrn'r(vl fru«n flris ul)plicatiurl. I, hereby, give consent to the Authorized Representative of the 1):11'ic Cululty Ile:lltll Dell: rill n j to enter upon above described property located in Davie County and ull•lied by Jade Assoc1 ates 41 , ILC to conduct all testing procedures as necessary to determine the site suitability. 3/15/04 DATL S1CNA'fUlZli ( �/ T1i1S AREA MAYBE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and prolmed properly lines alld din1C11SiOlIS, s(ructures, setbacks, and septic locations). Site Revisit Charge ---- Client Notification Date: E1.1s: Slgll giycll Arrnnnl No 131 lD S � 229.9 y` io r.J r 6,5,454 acs • "++ PA rON Pim. 09 t HOW.4 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: Tax PIN/EH #: Billed To:, Subdivision Info: Iu%Zt�S 11561'£ Reference Name: Location/Address: 1,p7- S , &#J t-.vr Proposed Facility: Property Size: Date Evaluated: Lt 3 �Sr Water Supply: On -Site Well / Community Public Evaluation By: Auger Boring •/ Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position 17 Slope % 9TT 5,10 HORIZON I DEPTH — Texture group Consistence '7 Structure Mineralogy HORIZON II DEPTH 3 Texture groupG �.} Consistence L Structure Mineralogy S-( HORIZON III DEPTH Texture group C.4 Consistence S Structure Ask Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION 75a<a LONG-TERM ACCEPTANCE RATE C. E? SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: PXA-X Irl TIAL- � . 1 %L rZxl�-a��zr✓�— 1pr 3 co 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)