164 Meadows Edge Drive Lot 16ti.
DAVIE COUNTY HEALTH DEPARTMENT �f
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990003552 Tax PIN/EH #: 5871-61-5955.16 TR
Billed To: Tate Rice Homes, Inc. Subdivision Info: Meadows Edge Lot # 16
Reference Name: Location/Address: Meadows Edge Dr. -27006
Proposed Facility Resiodence Property Size: 146'x 223'
ATC Number: 4034
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 Treatme and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CON B VAL FOR OD
OF FIVE YEARS.
Environmental Health Specialist's Signatu Date:
kl:!�—
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
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.
- - ' -O&Te- -7-Z3
Septic System Installed By:
r
Environmental Health Specialist's Signature: Date:
DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT 1
f. Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990003552 Tax PIN/EH #: 5871-61-5955.16 TR
Billed To: Tate Rice Homes, Inc. Subdivision Info: Meadows Edge Lot # 16
Reference Name: Location/Address: Meadows Edge Dr. -27006
Proposed Facility Resiodence Property Size: 146' x 223'
ATC Number: 4034
**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 Type 0 (), rs'1 . #People #Bedrooms 9 #Baths
Dishwasher: lt" Garbage Disposal: El"" Washing Machine: Er Basement w/Plumbing: ®� Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot SizeAA�P Type Water Supply CCOt—W Design Wastewater Flow (GPD) Ll 20 Site: New e Repair ❑
System Specifications: Tank Size IGMGAL. Pump Tank GAL. Trench Width Rock Depth ) 2'' Linear Ft. (O�
Other: ql-)Sral`c L 11Cy &- S
Required Site Modifications/Conditions: l Tt.. O.J CJ io2,Kr & W L-rp toevcu tc�� 1� aFF�aSc.µc
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)7.51-8760.****
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Mar 28 05 10:54a
t mar 14 05 11:40a
Tate Rice , 712-1986
davie county envhealth 336 751 0706 P.1
APPLICATION FOR SITE EVAU ATION/IMPROVEMENT PERMIT & ATC
Davie County Health Depatitnenl
DwirvAmeab/Heaft Seclfo/1
P.O. Box 848/210 Hospital Street
Mockaville, NC 27028
(3361751-9760
'eeeiltPORTAIITaee TSZS AP.MI ATION CUMOT 88 .PROCSSSM W:LESS ALL THS RZOulR20
INPORMAT20N ZS PROVIDED. /Racer to the 121701 O 12021 ZMATIlf for instructions.
✓l. Rome to be Billed fs.rC /t; %(� /)}�y„r.y�. ZG (-cuntaet rerwn
✓meillag Addre.a t'D eo, /& C/$aae thane -712
✓City/stata/zrp t(aftew"F7 11G 270/2 ✓su.in.as plwne 2906
,,-2. many on rsrmi C/ASC tr aiftUcLt than above Xw✓ �_
MallEng address city/state/zip
,-3 application For: 8'Site tlraivation ❑ 2myrovemeat permit/ATC p Both
.„i4. sratem to se—ico!�/e O Mobile Home 0 ausiaeso ❑ Zndustry 0 other
�S. ryp• or -tae, requested. t7 conwntioael i] conventional rodifled ❑ iAa e.tive
re. Zi Residence: a People-..,, s� a Bedrooms
a Bathroome 3 .
-- l�hvasher �rbage nispd..al earaahing Machine Q asemsnt/Plumbing ❑Besementheo Ploabiag
7. ze Buaiaeas/Zodustry /Other: verity type_ a People a slab
a Copmodea a :avaeere a ortoals N tater Coolera
IF FOODSE)MICEi 0 Santa Estimated Water Usage (gallons per day)
--I. Ty" of eater supplys 1 -'c .ty/City 0 Well ❑ consaunitp �.�
P. be yw anticipate additions at expansions of the facility this system Is intended to serve' 17 Yes 94fo
If yes, what t
I• !`(MPOI[TANZ*—CLMNT.;,M[AsTCO PtETETHEREQUIREDPROPERTYUIF'ORMATIONREOOFSTEo
DED91L— Either aPLAT orSI7£P rdESUBMITTEDbythecliest with THLSAPPLICATION.
7 �
L/Itroperty Dimensions: p / 22 3 --WRITE DIRECTIONS (from hlocksvi0c) to PROPERTY:
V. -T31 Officc PIN: Nilo 7I - is I S 7 SS
_-Property Address: Road Nattheten.
Cityllip
f in a Subdivision /roovide imformatdtnass tollows:
Name:
Section: Block ,_ Lot: Hfnte home corners Ragged: 3Z20 �S_
This Is to certify that the information provided is correct to the ben of my knowledge. 1 understand that any permits)
Issued hereafter are subject to auspemsi:-n or revocation, if the site pians or Intended use ohmage, or )( the information
submitted in this application Is falsified or C1120ged 1. also, tuiderstand that l esu MSPo)Ciblt for On raerges incurred from
this opplicativa 1, 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
to conduct all testing procedures as accessary to determine the site suitability.
L --DATE 3//- H [IL___ --s>GNATURE -Z
THIS AREA MAY BE USED FOR DR.6WING YOUR SITE PLAN (Include all of the following: Exhiing and proposed
property Goes and dkn md*c . structures, setbacks, and septic locations).
Site Revisit Charge
Date($):
Client No(itieation Date:
cf
Sign given Account No. r�
Revised DCHD (OSM3 Invoicr No• —. � 4 3 7
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44.76'- 26.00' 8 ' --_-- _ -----_
0 20.00' 44.78'
GARAGE 32.00'
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PROPOSED
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EC����E
DA
j51-1
fdVI 0T 11 .OUN{II�LTH
ON 1:011 SITE L'VALUATION/IAII'R0VL'AILN•f I'LUMIT & FITC
Davie County Health Department
EnYiroiimenta/Hea/t/i Section
P.O. Dox 840/210 Rospital SLrccL
Mocksville, PIC 27020
(336)751-07G0
***IMPORTANT*** THIS APPLICATION CANNOT DE PROCESSED UNLESS ALL THE REQUIRL•'ll _ I
INFORMATION IS PROVIDED. Refer to the INFORMATION DULLETIN for instructions. I
1. frame to be Dillcd Jade Associates I I , LLCCOAlan Jones
n LaC L' !'crass `
flailing Addreoo Post Office Box 4062 _ Lfomc phone _
Ci Cy/State/'LI1'
Winston-Salem,
I1C 27115-4062 (336) 759-9688
11UO1nL`00 1'hwie
2. ):a:uu on Permit/ATC if Uiffcrent than Above
Hailing Address City/SLaLe/Zip
1. Application For: i Site Evaluation ❑ Improvement 11cimiL/ATC 0 Duth
4. Syttem to Service: ® House ❑ 1•I0bile Honle ❑ Du:;ilic.'s ❑ IndusL•ry ❑ OLhcr
ti
S. Type system requested: ill Conventional ❑ conventional modified ❑ i„novaLive
G. If Residence. 11 People 4 1) Bedrooms 4 II Dathrou)u:. 2.5
bDiehwasher InGarbage Dioposal nWashing flachino 01jasomonL/110 plumbing
7. If Dusiness/Industry /Other: verify type 11 Pcohlc G :)lutes
0 Commodes 0 Showers 11 urirnalu 11 WaLcr Coolcru
IF FOODSERVICE: It Seats Estimated Water U::a1c (gallon:, par day)
S. Type of water supply: 1� County/City ❑ Well ❑ Conununity�,�S
9. Do you anticipate additions or CXIMISiullS of the facility (Itis systelll is ill(elillc(l to SL'1•\'e'1 ❑ Yes DCY No
If )'Cs, 11'llat tyl)C?
'•*tn1l'0JM1tYTk** CLILNTSMUST COM'LE71 'lIL REQUIRL'u REQUESTED —
IEL015'. Either a I'LAT or SITE PLAN 41USTBESU/ UMTED by the client irilh'I'lI1S �1l'I'LIC�\'PION.
Prul)crty Dinlcllsiulls:
Tax office 1'1N: 11
See attached map WRITE' UIRLCTIONS (IYunl fllucl;svilll) to I'I(UI'I:I(TY:
5871615955 Fast on Highway 158, turn right onto
Property Address: Road Nallle Beauchamp Road
City/Zip Advance, 27006
If ill a Subdivisioll provide iufurmition, as fullum:
Nat,lc: Proposed Jade Associates
Section: Block:Lot: 16
Gun Club Road and proceed to the end of
the road, turn left -onto Beauchamp Road
and the site is located approximately too
r,ii1es dorm Beauchamp Road on the right and
left side of the road. 3/8/04
Date Monte curners !lagged:
This is to certify that the information provided is correct to the best of lily Icllowledge. i understand (11.11 :uly 1)erwil(s)
issued hereafter are subject to suspension or revoca(ion, if the site plans ur intended use change, ur if the infurul:l(iun
subuli(Ied in this application is falsilied ur challged. I, also, 1111derslrucul that I aa) respuasible; fur• fill C/la)S'cs ill cur .d fru:)
!Iris upplicutiva. I, hereby, gi1•c conscut to [lie Authorized Representative of tllc D;i%,ic Cuun(y IlpAill Demr(u ca
ll
to cn(cr upon above described prupcl'ly lucalcd illDavic County and ulrucd by Jade Assoc( ates li I , LLG
(u cunduc( all testing procedurCS as uecess:u•y to dC(erlllinC file site suit:
DL' 3/15/04
A'I
SIGNATURE C_��✓
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of tllc fullolvin6 Existing and prupused
properly lines and dimensions, structul'Cs, setbacks, and septic locations).
Site Revisit Clcu-ge
lla(c(s):
Client Notilicaliuu Date:
MIS:
i
Sign given
,brans! Nn -3 1 V S
�r,j I:- + -73 7 1 —'
APPLICANT INFORMATION
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
Account #: 990003105
Billed To: Jade Associates II, LLC
Reference Name:
Proposed Facility: Residence Property Size:
PROPERTY INFORMATION
Tax PIN/EH #: 5871-61-5955.16
Subdivision Info: Prop. Jade Assoc. Lot # 16
Location/Address: Beauchamp Rd -27006
see map Date Evaluated: 3'2cc�ty�
Water Supply: On -Site Well Community _ Public
Y
Evaluation By: Auger Boring Pit Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
Slope %
^
HORIZON I DEPTH
,1In
p - 2
Texture group
Consistence
Structure
31�
Mineralogy
HORIZON II DEPTH
1 tp - Z
2,5'41
Texture group
C 4
: L 54
Consistence
'tcrS
Frf3
Structure
Mineralogyt
HORIZON III DEPTH
Texture group
Consistence
NS
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
5
CLASSIFICATION
S
LONG-TERM ACCEPTANCE RATE
-
e.35 �C•
SITE CLASSIFICATION: P_�
LONG-TERM ACCEPTANCE RATE: Q— 55 ' p'(A
REMARKS:
LEGEND
Landscape Position
EVALUATION BY: <AAfC—
OTHERS) 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)