111 Meadows Edge Drive Lot 2DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. sox 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990003476
Billed To: Fowler -Jones Construction
Reference Name:
Proposed Facility Residence
ATC Number: 4103
Tax PIN/EH #: 5871-61-5955.02 FJ
Subdivision Info: Meadows Edge Lot # 02
Location/Address: Meadows Edge Dr. -27006
Property Size: see map
As stated In 0A NCAC 18AASGS(5)
accepted Systema 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 .1 0 Sewa Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WAS T RU IO IS V4TOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signa e: Date: 1 f
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 1,1 of .S. apt I A, Section .1900 "Sewage Treatment and
Disposal Systems," but shall in NO WAY Mak as nt that the system will function satisfactorily for any
given period of time.
I 3r
erj" V141
1
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Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
V- �J
Date: �7,d /rJ �� ✓
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
' P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 (�
IMPROVEMENT/OPERATION PERMIT
Account #: 990003476 Tax PIN/EH #: 5871-61-5955.02 FJ
Billed To: Fowler -Jones Construction Subdivision Info: Meadows Edge Lot # 02
Reference Name: Location/Address: Meadows Edge Dr. -27006
Proposed Facility Residence Property Size: see map
ATC Number: 4103
**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 1 I 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 1405E #People #Bedrooms 3 #Baths 3
Dishwasher: 1?r— Garbage Disposal: [ae" Washing Machine: Ef" Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size 0 (09 Via✓ Type Water Supply et'1YDesign Wastewater Flow (GPD) Site: New C?"Repair ❑
System Specifications: Tank Size 1000 GAL. Pump Tank GAL. Trench Width --zi- Rock Depth 1Z Linear Ft.40C
Other:so__.111�= , ,�
Required Site Modifications/Conditions: llntbl-L (>N r i 01 I L7' car L► LS
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.****
Zr-' �ptcd S tcrosf nay also .be M d
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Environm th Sp ; is Signature:
----
DCHD 05/99 (Revised)
Jan 26 05 10:10a davie county envhealth 336 751 8786 p,3
-,Lu1 E O U E
JUN 1 0 2005
EJJVIRo%nENTAL HEP, H
DAVIECOTITY_ ____
CATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Health Department
Environmental Health Section
P.O. Box 846/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION 15 PROVIDED. Refer to,xhe INFORMATION BULLETIN for instructions.
1. Name to be Dilled RUy*Vr�U11',`
Mailing Address ±)(+qj ^
City/state/ZIP
2. Name on Permit/ATC if Differeut than Above
Contact Person —Cl �In�-1_ jnrle�S
Home Phone
Business Phone 336-769.9&g3
Hailing Address �C,.,i/ty/Stato/Zip
3- Application For: ❑ Site Evaluation qi Improvement Permit/ATC ❑ IIoth
4. system to Service: House ❑ Mobile Homo ❑ Business ❑ Industry ❑ Other
S. Type eyetem requested: d Cor•rontional ❑ conventional modified ❑ innovative
6. If Residence: # People # Bedrooms 1 J
— # Bathrooms
EaDishwashor OGarbago Dispcaal Washing Machine. ❑Basement/Plumbing ❑Basement/No Plumbing
7. if Business/Industry /Other: verify typo•
# Commodes # Showers
IF FOODSERVICE: # Seats
8. Typo of water supply: 4 county/city
# People # Sinks
# Urinals # Water Coolers
Estimated Water Usage (gallons per day)
❑ well
❑ Community
9. Do you anticipate additions or Cx172115i0lls of (lie facility this system is intended to serve? ❑ Yes ❑ No
If yes, Ivllat type?
***IMPORTANT*** CLIENTS AfUSTCOAIPLETETIIE REQUIRED PROPERTY 1NI-ORMATION RCQUCSTCD
BELOW. Either n PLAT or SITE PLAN AfUST BE SUBAUTTED by the client witli THIS APPLICATION.
Property Dimensions: 4d, S X, '234, 0 (. k 17A
Tax Office PIN: #
• X11 (ol�t'S5 �.►c�, 89
1VRITC DIImECC10NS (from Mucluville) to PROPERTY:
Property Address: RoadNanic_yi�Fc�dcaw�(` ��lr 4'2;ohi- P)aVirnoro fart_ SOLA6.
City/Zip Advo �; r , d '] a O b C e -f + - �QO tiCi .nn rn iP J,
If in a Subdivision provide inforntati in, as follows:
Name: Mpodc)eea,s 'cine,
Section: Block: _ Lot: J Date honie corners flagged:
This is to certify that the information p.-ovided is correct to the best of my knowledge. 1 understand that any perinit(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 jar all charges incurred jruln
this application. I, hereby, give consent to the Autliorized Representative of the Davie County Ncalth Department
to enter upon above described properly located in Davic County and owned by_ ca •�� l c�i• _ j�,� Car�!7 Fr u L) r) Co
to conduct all testing procedures as nea:ssary• to determine (lie site saiin!ability. �+
DATE A- r - O SIGNATUREA�i.
TRIS ARRA MAY BE USED FOR DIULWING YOUR SITE PLAN (Include all of tlic following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Sign given
/yy
Revised DCIID (05/03
Site Revisit Cliarge
Datc(s):
Client Notification Date:
EIIS:
Account No. 3 l
Invoice No.S
40
O
GRAPHIC SCALE
MEADOWS EDGE DR.
(PUBLIC 50' R/W)
O
0 20 40 so / / 160
NOTE,
SURVEYOR HAS MADE NO INVESTIGATION OR INDEPENDENT SEARCH FOR
EASEMENTS OF RECORD, ENCUMBRANCES, RESTRICTIVE COVENANTS,
OWNERSHIP, TITLE EVIDENCE, OR ANY OTHER FACTS THAT AN ACCURATE
( IN FEET ) AND CURRENT TITLE SEARCH MAY DISCL❑SE, THIS SURVEY IS PERFORMED
I inch = 40 fL WITHOUT THE BENEFIT OF A TITLE SEARCH.
NOTICE:
FOWLER JONES CONSTRUCTION HAS VERIFIED TO ALLIED LAND
SURVEYING COMPANY, P.A. THE EXTERIOR HOUSE DIMENSIONS FOR THIS
EXISTING HOUSE/STRUCTURE. HOUSE POINTS AND POSITION SHOWN ON
THIS MAP REPRESENT THE POINTS TO BE PLACED ON THE PROPERTY.
THE OWNER/CONTRACTOR HAS REVIEWED ALL HOUSE/STRUCTURE
DIMENSIONS, SETBACKS FROM PROPERTY LINES, AND COMPLIANCE WITH
RESTRICTIVE COVENANTS AND/OR LOCAL GOVERNMENTAL
REQUIREMENTS ON THIS DRAWING AND BY THEIR SIGNATURE
AUTHORIZES ALLIED LAND SURVEYING COMPANY, P.A. TO PLACE THE
POINTS AS ACCURATELY AS IS REASONABLE (TYPICALLY 0.02'±).
OWNER /CONTRACTOR TO VERIFY THE PLACEMENT OF POINTS SET IN
FIELD PRIOR TO AUTHORIZATION OF FOOTINGS/BRICK MASONS/
CONSTRUCTION TO PROCEED. BY SIGNING THIS STATEMENT OWNER/
CONTRACTOR FULLY ACCEPTS THEIR RESPONSIBILITY TO VERIFY
POINTS IN FIELD. THE HOUSE POINTS DENOTED BY SOLID FILLED
CIRCLES ARE THE ONLY POINTS TO BE LOCATED IN THE FIELD. ALL
OTHER BUILDING CORNER LOCATIONS ARE TO BE THE RESPONSIBILITY
OF THE UNDERSIGNED CONTRACTOR/DEVELOPER.
ACKNOWLEDGMENTS DATEi
OWNER/CONTRACTOR
FIELD REVISION: -------------------------- DATE,
---------------------
OWNER/CONTRACTOR/ALLIED STAFF
PRELIMINARY LAYOUT
LOT 2
'Meadows Edge'
Phase 1
Plat fors Alan Jones
ALS PROJECT N0i 9875
NOTE:
THIS PLAT DOES NOT REPRESENT A CURRENT FIELD SURVEY. ALL LOT
DIMENSIONS HAVE BEEN TAKEN FROM THE PLAT OF MEADOWS EDGE,
PHASE 1, LOCATED IN PLAT BOOK 8 PAGE 143. NO TITLE RESEARCH
HAS BEEN PERFORMED OR REQUESTED FOR THE BENEFIT OF THIS PLAT