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195 Meadows Edge Drive Lot 11. �47 DAVIE COUNTY HEALTH DEPARTMENTV-- 0-J Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003530 Tax PIN/EH #: 5871-61-5955.11 Billed To: Robbins Construct.Co., Inc. Subdivision Info: Meadows Edge Lot # 11 Reference Name: Location/Address: Beauchamp Road -27028 Proposed Facility Residence Property Size: see map ATC Number: 4129 As awed In IDA N04 15d acceptod iGystems may a so a use 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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1990,ewa a Trea t and Disposal Systems). THIS AUTHORIZATION FOR WASTEW =VAIDERIOD OF FIVE YEARS. Environmental Health Specialist's Signatur : ate: S� Y, *NOTE** The issuance of this Certificate M has been installed in compliance 13 9y Disposal Systems," but shall in T given period of time. b -i4tea%. 7-3D TE OF COMPLETION shall indicate the system described on Improvement/Operation Permit 1 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and ken as a guarantee that the system will function satisfactorily for any Septic System Installed By: Environmental Health Specialist's Signature: 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 #: 990003530 Tax PIN/EH #: 5871-61-5955.11 Billed To: Robbins Construct.Co., Inc. Subdivision Info: Meadows Edge Lot # 11 Reference Name: Location/Address: Beauchamp Road -27028 Proposed Facility Residence Property Size: see map h=>0 ATC Number: 4129 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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 JAS `'= #People #Bedrooms 3 #Baths 2 + Z -z Dishwasher: u Garbage Disposal: ff— Washing Machine: Basement w/Plumbing: 0 Basement/No Plumbing: 0 Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 0 Lot Size 1. Z Type Water Supply Call Y Design Wastewater Flow (GPD) Site: New Repair System Specifications: Tank Size 10CCGAL. Pump Tank GAL. Trench Width��a Rock Depth M' Linear Ft. 1/V0 f _c As stated In 15A NCAC 18A.188�(5 Other: �1 Q1�t�ii~ accepted Systems may also be uc-d Required Site Modifications/Conditions: %TQll ©j Chi. uOZ, � ZS f� h� « � L'"�r 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�M-8760.**** Environmental Health Specialist's DCHD 05/99 (Revised) Lj j I • �1A�c Jam- 36 Date: APPLICATION FOR SITE EVALUATION/IMPROVE&IENT PERMIT Davie County Health Department Q V Environmental Health Section P.O. Box 848/210 Hospital Street LION Mocksville, NC 27028 ,2005 (336) 751-8760„•._ ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE RMQ INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed /p,� 1, jf� Cr:ka' j14'e - Contact Person �Z2 Mailing Address �/�,�+1%;r/�i ii�f,�T /” Home Phone City/State/ZIP �rriyl`ifyl`i%- ilt�/� Business Phone1Y�^�l 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: ❑ Site Evaluation city/state/zip lel Improvement Permit/ATC ❑ Both 4. System to Service: M House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. Type system requested: 19Conventional ❑ conventional modified ❑ innovative t3acCepted 6. If -Residence: # People # Bedrooms # Bathrooms a ishwasher (Garbage Disposal LYWashing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks — # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) s. Type of water supply: -[County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes, what type? ***IMPORTANT'** CLIENTS MUST COMPLETE THERE PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client witli THIS APPLICATION. Property Dimensions: Ao—e . Tax Office PIN: 11 ��� — / _ SS SS•/� Property Address: Road Name�a-`' City/Zip If in a Subdivision provide information, as follows: Name: / ' P"- ') ") S Section: Block: Lot: 1 WRITE DIRECTIONS (from Mocksville) to PROPERTY:` != / S -e A CC -,'6- c.> F /` a ..c._A cd /'-J a �— /vim J' Date home corners Ragged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any peruiil(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 ani responsible for all charges incurred from 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 to conduct all testing procedures as necessary to determine the site suit bility 7 DATE SIGNATURE _ 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 Revised DCHD (05/03 Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. � q Invoice No. / S _ 4v WOO C) ,. pZ.` JJo ss 3 01 LLJ p w 9 L 68 a ti J1/9 8/ /VEAlock1S f�L-,e db)2/vrZ-- "-/ 6 -1--Az� I I S Co ,3, -7 2,:, . ZJC- )-u oSSA -L 39 9 - 4 77$ ENVIRONMENTAL HEALTH DAV IE COUNTY N 1011 SITC• EVALUATI0N/IMI'Ii0VL111EN1_ 1 UMIff S !1'f(; Davie County Health Department ,&I Yi/"011111 e17 t,71 fleaitil 5eCtiO/l 1.0. Dox 040/210 Hospital Strcct Nocksville, NC 27020 (33G) 751-0760 ***II.IPORTANT*** THIS APPLICATION CANNOT DE PROCIiSSL'D WILLSS ALL TUE REQUIRLD I INFORMATION IS PROVIDED. Refer to Cho INFORDIATION BULLETIN for insLrUCL:iorll. Jade Associates II, LLC Alan Jones 1. Name to be Dillcd Con CaCC Pcr;:on Mailing Address Post Office Box 4062 ilo c llfutlo City/Sts Lc/'LIP Winston-Salem, NC 27115-4062 (336) 759-9688 11UD1t1Ut7D 1'huue 2. Namo on Pcrmit/ATC if Different Chan Above Hailing Address City/SLaCc/Zip __ 3. Application For: M Site Evaluation 4 ❑ ImprovchlenL Permit/ATC 4. Syctem to Service. 12 House ❑ Nobile !Ione ❑ Du;;iilcL'D ❑ InduDtry L4 5. Type system requested: M Conventional ❑ conventional modified 4 4 ❑ OLhC:r ❑ innova Live 6. If Residence: y, 11 People I) Bodrooln� iLUishwasher ICIGarbaye Disposal nViashing Machino ENL;aScuWnt/1'lwnbiuU 7. If Dusincas/Industry /oLher: verify type 11 1'coplc 11 Co"-iodes 11 Showers 11 Urilnalu ❑ 11ULh II UaLllrounl:. 2.5 ❑Da¢:emcnL/flu vlunibing Il WaLcr Coolcru IF FOODSERVICE: Il seats Estimated WaLer UcagC (gallolla per day) B. Type of water supply: In County/City ❑ well U Conuuunil'yt� 9. Do you anticipate additions or CNI)WISiolls of the facility this System i; ill(clldcd to Serve? ❑ yes 9ZG No If )'CS, 11 Ila[ type? "*IAI1'0X(AjYT*** CLILNTSMUST C0A1PLL•'TE'r1IL 1U QU1RL•'D PROI'LI(TY 1NVORNIATION RLQUE, "'IS) --_I BELOW. Either a PLAT or SITE PLAN dIUSTBCSUllt1!!r1'CD b)' tlic dial! ,rilll'I'1lIS Al'I'1,IC�\'PION. 1'ruperly Dimensions: See attached map 11'1(hfL UIRLCTIONS (frim A-lurltsvilic) U) VROVL (TY: 'iaz Office PIN: it 5871615955 East on Highway 158, turn right onto Property Address: Road Name Beauchamp Road GWI Club Road and proceed to the end of City/"Lip Advance, 27006 tvie road, turn left -onto Beauchamp Road If ill a SUbdiviSioll provide iul'urulaliou, as fUllUly5: Nallic: Proposed Jade Associates Section: Block: Lot. 11 and the site is located approximately Wo rii1es dorm Beauchamp Road on the right and left side of the road. 3/8/04 Date !ionic curuers !lagged: This is to certify that Ilse information provided is correct to the best of my knowledge. 1 understand that :1113' periiiil(s) issued hcreafler arc subject to suspeusiotl or 1•evocatioll, if (lie site plans or intended use ciculge, or if the infurnia(ion subnli((ed in this application is falsilied or changed. I, also, understand that I ant respunsible for all charges incit rnW/tial this application. I, hereby, give consent to the Authorized Rcprescutativc of the Davie County llealth Det):11111 cu to enter upon above described properly luca(ed in Davie County and u1l,ncd b3 Jade P,ssoC1 Ates 41 , -LLG to CUBLIUCI all testing procedures as ucccssary to deterinilte (lie site suitability. 3/15/04 DATL SICNATURI; TRIS AREA MAYBE USED FOR DRAWING YOUR SITE PLAN (Include all of (lie fullowhig: Lxislin6 and propusetl properly lines and dimensions, structures, setbacks, and septic locations). Site Rerisil Charge ll nlc(s): Client Notificatiuu Dale: ENS: Sip gk'cll A\rrnnnf Nn DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • SoiVSite Evaluation APPLICANT INFORMATION Account #: 990003105 Billed To: Jade Associates II, LLC Reference Name: Proposed Facility: Residence Property Size Water Supply: Evaluation By: On -Site Well Auger Boring_ PROPERTY INFORMATION Tax PIN/EH #: 5871-61-5955.11 Subdivision Info: Pro Jade Assoc. Lot # 11 Location/Address: Beauchamp Rd -27006 see map Date Evaluated: I ?- o q'1 &104 Community Pit Public Cut FACTORS 1 2 /3 4 5 6 7 Landscape position C_ C Sloe % -7 7 HORIZON I DEPTH Texture groupt✓ Consistence F: Structure 95 1L Mineralogy< HORIZON II DEPTH 31 '' S 1-7- 4 Texture group Consistence Structure $ 94 Mineralogy • " HORIZON III DEPTH U 5— Cc Texture group•G : C , Consistence S $S Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE s S t7 CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: 3�Q> LONG-TERM ACCEPTANCE RATE: 0'� 'y REMARKS SL MAI° f:�4 Mbk"' RoLe 't�TQ1S Landscape Position y EVALUATION BY: OTHER(S) PRESENT: 11 ^ . 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)