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142 Meadows Edge Drive Lot 22• DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003530 Tax PIN/EH #: 5871-61-5955.22 Billed To: Robbins Construct.Co., Inc. Subdivision Info: Meadows Edge Lot # 22 Reference Name: Bart Lunsford Location/Address: Meadows Edge Dr. -27006 Proposed Facilitv: Resi ATC Number: 4392 As stated in 15A NCAC 18A.1969(5) accepted Systems may also be used 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 Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CO N IS ALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signa e: Date: CERTIFICATE OF COMP * *. I(OTE* * The issuance of this Certificate of Completion shall indicate $v has been installed in compliance with Article 11 of G.S. Cha G�� Disposal Systems," but shall in NO WAY be taken as a guar given period of time. e�vccx y s� c IA,P-JK D4IG- q -1a Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) A G V �0ty.->r, FST I—� ��►,�� :d on Improvement/Operation Permit .1900 "Sewage Treatment and n will function satisfactorily for any M al • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ' P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990003530 Tax PIN/EH #: 5871-61-5955.22 Billed To: Robbins Construct.Co., Inc. Subdivision Info: Meadows Edge Lot # 22 Reference Name: Bart Lunsford Location/Address: Meadows Edge Dr. -27006 Proposed Facility: Residence Property Size: 134x229 **NO T E9*N v m leer: 4392 is mprovement/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 Type t4(O%SS #People #Bedrooms Lf #Baths �. 5 Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ff" Basement/No Plumbing: ❑ Commercial Specification: Facility Type nn #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water SupplyDesign Wastewater Flow (GPD) Site: New Repair ❑ System Specifications: Tank Size IMDUAL. Pump Tank GAL. Trench Width —&1, Rock Depth 12.E Linear Ft j�f As stated in 15A NCAC 18A.1969(5 Other: acee ted Systems may also be use Required Site Modifications/Conditions: hi 5Tau ©r� ca -,l Toop V-e�,& 15 1 OFF -j � ?, P 1 Dow poop. 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.**** �M4Xr`T�NC�f `�`PrFt 3�,, LI PJES W opbe:�, 4E A►� t7`• sr ,� I Environmental Health Specialist's Signature: Date: JAW DCHD 05/99 (Revised) TION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC ---�""� Davie County Health Department t5 Environmental Health Section U P.O. Box 848/210 Hospital Street 3 ��� Mocksville, NC 27028 ,JAY _ (336) 751-8760 ** Ij�IS APP ICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORA �{tZXMI /AIRefer to the INFORMATION BULLETIN for �instructions. 1. Name to be Billed &268/MS Lbs� Co..L^N^ C- Contact Person BAP, 1 L. aN).SrOl—b Mailing Address 1-53/1 57W L/Ai c, I oA.EST t /Z Home Phone `` 4Q 4--77Y' 1�f 7a moi' City/State/ZIP �,�J/hp�$, , ArC_ 2- 70/Z Business Phone w4l 37-/ " 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to service: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. Typo system requested: X Conventional ❑ conventional modified ❑ innovative 92aCCepted 6. If -Residence: # People # Bedrooms # Bathrooms ADiahwasher ❑Garbage Disposal Washing Machine Basement/Plumbing ❑Basement/No Plumbing 7. I£ Business/Industry /Other: verify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 8. Type of water supply: 0 County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes gNo If yes, what type? ***IIIIPOR:(ANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: 134 tK ZZr! I WRITE DIRECTIONS (from Nlocksville) to PROPERTY:,` Tax Office 11IN: # :!rg%/ 4. / AW V 1$ JV -7b G "A) e.L k S KZ b Property Address: Road Name IKfz, b&Ai 5 G (to/ C" A kb 7`0 -8VA" i4AM I0 Rt) City/zip A1:✓'41VCF—' 46per ow 6m4cmwP 7b If in a Subdivision provide information, as follows: MDAbO war B%G a Ont Name: /►'/LCE}2 n w s EZNG E' -4 *4 J,.o i 6A1 LE -r-1 Section: Block: Lot: 2 Z Date Home corners flagged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred froun this application. I, hereby, give consent.to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by KOBa," Conl Z i': %p. -r—A1 C— to conduct all testing procedures as necessary to determine the site suitability. DATE :511 o G SIGNATURE Z(L A TIIIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Sign given Site Revisit Charge Datc(s): Client Notification Date: EIIS: Account No. (253V Revised DCHD (05/03 Invoice No. X34' ti N N �tiDCG� Y. i4ou S FZ —7L 4,o' .S3/2 ,,L4 MEa�o�s .301 I_ /s N t2o33 •N s Co,,� 5% Co, - CA"U)LAX5 46 6- -- JSL 4 = 3© n C E D tiJ ' iv"A`rt 1 5 2004 Al J ENVIRONV'ENTAL HEALTH DMIE COUNTY ON 1013 SITE !:VALUATION/1A1N110VL•AILNT 1'E1011.1• & ATC Davie County Health Department EnvirOna1enta/f/ea/t/1 Section P.O. Dox 040/210 ilonpital StrCCL Mockoville, PTC 27020 (336)751-0760 ***IMPORTANT*** THIS APPLICATION CANNOT DE PROCESSED UIILLSS ALL THE REQUIRED INFORMATION IS PROVIDED. Refor to L•ho INFORMAI'ION BULLETIN for incL•>:ucLionLj. Jade Associates II, LLC Alam Jones 1. Name to be Dillcd ConLacl' Posen Mailing Address Post Office Box 4062 Ilomc Phunc City/State/'LIP Ilinston-Salem, NC 27115-4062 Dusinuus 1'huuo (336) 759-9688 2. Namo on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: if Site Evaluation i ❑ Improvo llenL PermiL/ATC L1 DoLl1 9. System to Service: ® House ❑ 1•101:zile Home ❑ Dusinci,n ❑ Industry ❑ OL•lrcr_- ti, S. Type system requested: Iii! Conventional ❑ conventional modified ❑ innovaLivu G. If Residence: a People 4 Il Bedrooms 4 II Dath oam, 2.5 tDiDllwasher InGarbage Disposal KlPlashing blachino MDa!,cmcnL/Plwnhing [Ilia Lowell t/No Plumbing 7. If Business/Industry /Other: verify type I1 Pcoplo U Sinks — — N Commodes II Showers II Urin,ilu II WaLur Coolcru IF FOODSERVICE: I1 SeaL•n Estimaued Water Usage (Uallon:, per day) 8. Typo of water supply: I� County/City ❑ wall ❑ Conuuunity 9. Do you anticipate additions or C\I).UISio11S of (lie f:lcillly this System is illll't,dcd to serve? ❑ Yes No Irycs, 11 -hat type? A** IAII'01(Til/YT*** CLI1sN'fSB1US'TCOAII'LLTL 'rl1L /tL�I U!/(L'U 1'1(Ol'LI('1'1' 1N1�01((1�IA'l'lON Itl:L 111;S'I'h;l) BELOW. Either i PLATor SITE PLAN r(1USTQESUB,IfIT17'U by the client gill,'!'Ill�,\PfLIC.1'1'ION. 1'rupt:11)• Dimensions: See attached map 11'ltl'I'L Ull(L'CTIOI`IS (frulu (lluch.wille) to 1'1(0I'EI('I'1': 'fax Officc 1'IN: ll 5871615955 East on fii ghway 158, turn right onto Property Address: Road Name Beauchamp Road City/'Lip Advance, 27006 If ill a Subdivision provide iu1'urrltation, as fullulvs: Name: Proposed Jade Associates Section: Block: Lot: 22 GUn Club Road and proceed to the end of the road, turn left -onto Beauchamp Road and the site is located approximately too miles dolor Beauchamp Road on the right and left side of the road. 3/8/04 Date Mollie corners 11a6ged: This is to certify that the iuformaticla provided is correct to the best of my knowledge. I ululersland (flat any perulil(s) issued hereafter are subject to Suspension or revocation, if the site plalls or illtclldcd use change, or if the infurum(im submitted in this applicalioll i5 falsified or changed. 1, (tlso, tuttlerstanil that I am req)urrsible fur all ckmu gcs incur•rol from this applicutiou. I, hereby, gi1'c conscut to (lie Authorized Representative of the D:lvic Cuuuty Ilc:ll(Il 1)cLL,:l!r(u c„i1 to enter upon above described property located in Davie County and vlvrlcd by Jade Assoc] Ates 11 , LLG to conduct all (esliug procedtN'cs as accessary to determine the site suitability. _ 3/15/04 DA'I'S SIGNATURE TINS AREA MAYBE, USED FOR DRAWING YOUR SUE, PLAN (Include all of the fullowing: Existing and 1)ropused property lilies and dimensions, structures, se(bac!(s, and septic localiolls). Sitc Revisit Cluu'ge D a(e(s): ---- Client Notification Date: Elis: Sip giml Arrnnnt Nn DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003105 Tax PIN/EH #: 5871-61-5955.22 Billed To: Jade Associates II, LLC Subdivision Info: Pro Jade Assoc. Lot # 22 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 M Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope % Yk HORIZON I DEPTH ^ ) Texture group Consistence LZ Lj/ Structure C Mineralogy HORIZON II DEPTH Texture group Consistence —; Structure jC 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 Ll SITE CLASSIFICATION: VS LONG-TERM ACCEPTANCE RATE: 6I REMARKS: EVALUATION BY: c) eW— 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)