563 Juney Beauchamp Rd Lot 1 Davie County,NC Tax Parcel Report Tuesday, December 20, 2016
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WARNING: THIS IS NOT A SURVEY
777
Parcel Information
Parcel Number: - E700000052 Township: Farmington
NCPIN Number:- - 5861624335 Municipality:
I
Account Number: --_ 8304386 Census Tract: 37059-803
Listed Owner1: _ PIEDMONT.NEWS COMPANY INC Voting Precinct: SMITH GROVE
Mailing Address 1: - 150 MUIRFIELD DRIVE Planning Jurisdiction: Davie County
City: -- WINSTON SALEM Zoning Class: DAVIE COUNTY R-20
State: NC Zoning Overlay: DAVIE COUNTY QD
Zip Code: 27104 Voluntary Ag.District: No
- Legal Description: 1.240 AC LOT 1 S K BEAUCHAMP Fire Response District: SMITH GROVE
Assessed Acreage: 1.24 Elementary School Zone: PINEBROOK
Deed Date: 10/2014 Middle School Zone: NORTH DAVIE
Deed Book/Page: 009710744 Soil Types: GnB2
Plat Book: 11 Flood Zone:
Plat Page: 371 Watershed Overlay: DAVIE COUNTY
Building Value: Outbuilding&Extra
Freatures Value:
Land Value: Total Market Value:
Total Assessed Value:
101 All data Is provided as Is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the
Davie County, Implied warranties of merchantability or fitness for a particular use.All users of Davie County's GIS website shall hold harmless the
County of Davie,North Carolina,Its agents,consultants,contractors or employees from any and all claims or causes of action due to
NC or arising out of the use or Inability to use the GIS data provided by this website.
CONSTRUCTION For office use only
` AUTHORIZATION *CDP File Number 161083.2
Davie County Health Department county l0 Number.
5861-62-4335-01�
210_Hospital Street ; Evaluated For. NEW +•
P.O. Box 848 ;
�•�«...�• Township:
MOCksville� J -�NC` 27028 PERMIT VALID UNTIL:
Phone:336-753-6784 Fax:336-753-1680 1 1 / 3 0 / a 0 a 1
-Applicant.; Maxey Builder-Inc Property Owner: Piedmont News Company Inc
-Address: 118-Andrew Acres Rd 'Address: 150 Muirfield Dr
W--City: Kernersville City: Advance
- -State2ip: NC 27284 StatefZip: NC 27006
- -Phone#: (336)749-6233
one#:
Property Location &"Site Information
r.Addcress/Road #: Subdivision: SK Beauchamp Phase: Lot: 1
ney Beauchamp Rd
vance NC 27006 Directions
H 158, Right on June Beauchamp Rd, Property on left
Structure : .`SINGLE'FAMILY � - wY; 9 Y P P rtY
just before Baltimore Rd.
#of Bedrooms: 4
#of People: 2
*Water Supply: PUBLIC
- - System Specifications
Minimum Trench Depth: 3 6
Site Classification Provisionally suitable - 71nchesMinimum Soil Cover. a 4Saprolite System? QYes. . _®No Design`Flow: --' 4 $ 0 Maximum Trench Depth: 36
Soil Application Rate: Maximum Soil Cover.
0 3 a 4 Inches
"System Classification/Description '-- 'Distribution Type: PUMP TO GRAVITY
TYPE III G.OTHER NON-CONN TRENCH SYSTEMS Septic Tank:
1 0 0 0 _ Gallons
'Proposed System:'25°io`REDUCTiON 1-Piece: OYes @No
Pump Required: @Yes ONo OMay Be Required
Nitrification Field 1 6 0 0
Sq. ft. Pump Tank: 1 0 0 0 Gallons
No. Drain Lines 4 1-Piece: OYes @No
Total Trench Length: 4 0 0 ftGPM vs— ft. TDH
Trench Spacing: _ 9 Feet Onches
C O.C. Dosing Volume: _ Gallons
O
Trench Width: (J Inches
_
3 Feet . Grease Trap: Gallons
Aggregate Depth: inches PreTreatment: ONSF OTS-) OTS-II
Septic Tank InstallerGrade Level Required: OI 0711 O III OIV
Dnna i of Z
'
CDP File Number 161083 -2 County ID Number..5861-62 X4335-01
y ❑ Open Pump System Sheet_
Repairsystem Required:@Yes ONo ONo, but has Available Space
�eyair System
= Trench Spacing: 9 Inches 0.
*Site Classification: Provisionally_Suitable - _ - Feet O.C.
-, Trench Width:
3 Inches
Design Flow. Feet
Soil Application Rate:_-0_ —3 . -_` Aggregate Depth: inches
- Minimum Trench Depth: 3 6
*System Classification/Description: Inches
TYPE III G:OTHER NON-CONV.TRENCH SYSTEMS Minimum Soil Cover: 2 4 Inches
Maximum Trench Depth: 3 6
*Proposed System: '25%REDObTION Inches
Maximum Soil Cover: a 4
Nkrification Field 1 6 0 .0 Inches
Sq.ft.
No. Drain Lines` J *Distribution Type: PUMP TO GRAVITY
4
7:Total.Trench Length 4' 0 0 Pump Required: QYes ONo May Be`Required
!77r ONSF OTS-1 OTS-II
*Site Modifications
No grading or construction activity is allowed in'areas-designated for system and repair without approval of Health Department.
*Permit Conditions
The._issuance.of this permit by.the Health Department in no way guarantees the issuance of other permits.The permit holder"
_is responsible:for checking with appropriate governing bodies in meeting their requirements. ;
This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit,not
—to exceed five years,-and maybe Issued at the sametime the Improvement Permit Issued(NCGS 130A-336(b)}If the Installation has not been
completed during the period of validity of the Construction Permit,the information submitted in the application for a permit or Construction
Authorization is found to have been incorrect,falsified or changed,or the site is altered,the permit or Construction Authorization shall become
Invalid,and may be suspended or revoked(.1937(g)).The person owning or controlling the system shall be responsible for assuring compliance
with the laws,rules,and permit conditions regarding system location,installation,operation,maintenance;monitoring,reporting and repair
(1938(b)).
Applicant/Legal Reps. Signature Required? Oyes ONO
Applicant/Legal Reps.Signature: Date:
*Issued By: 2tao-Nations,Robert Date of Issue: _ 1 1 / 3I 0 / a 0 1 6
Authorized State Agen Malfunction Log QYes
@Hand Drawing Olmport Drawing
Site Plan/Drawing attached.
Page 2 of 3
i
- CONSTRUCTION AUTHORIZATION
T Davie county Health Department " CDP File Number: 161083 -2
210 Hospital Street --. -- "
5861.624335-01
County File Number:
.P.O.Box 848
Mocksville - NC = 27028 Date: 1 1 / 3 0 / 0 1'b -
Q Inch --
Construction Authorization Scale: , QBlockDrawing Drawn ype: = ft.
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CONSTRUCTION AUTHORIZATION
- {
Davie County Health Department
Hosp;tai sheet - 161083-2
_ CDP File Number:
P.O Box 848 -5861 -62-4335-01,.-,.
Mockswle NC 27028 County File Number _.. _ '
Date: 1 1;/ 3 0 12 0 1 6
,.Click-below to lmpoff an linage from'an`extemai location: Drawing Type:Construction Authorization
.t
CONSTRUCTION For office use only
AUTHORIZATION *CDP File Number 161083-2
Davie County Health Department County ID Number.5861-624335-01
210 Hospital Street Evaluated For. NEW
P.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone: 336-753-6780 Fax:336-753-1680 0 9 / a 7 / a 0 a 1
Applicant: Maxey Builder Inc Property Owner: Piedmont News Company Inc
Address: 118 Andrew Acres Rd Address: 150 Muirfield Dr
City: Kernersville City: Advance
State0p: NC 27284 'State/Zip: NC 27006
Phone#: (336)749-6233 Phone#:
Property Location & Site Information
Address/Road# Subdivision: Phase: Lot: 1
Juney Beauchamp Rd
Advance NC 27006 Directions
Structure SINGLE FAMILY1� wy:158, Right on Juney Beauchamp Rd, Property on left
I�� `� Jd�F0dt before Baltimore Rd.
#of Bedrooms: 9 '5,,, )4r . Q 'bed
#of People:
*Water Supply: PUBLIC V,
System Specifications
Minimum Trench Depth: a �
KSitessification: Provislonauysuitabte Inches
Minimum Soil Cover. 1 2e System? OYes @No Inches
Design Flow: 3 6 Maximum Trench Depth: 3 6 Inches
Soil Application Rate - Maximum Soil Cover. a 4 Inches
*System Classification/Description: '"Distribution Type: PUMP TO GRAVITY
TYPE 111 B.SYSTEM W/SINGLE EFFLUENT PUMP Septic Tank: 1 0 0
_ Gallons
"Proposed System: 25%REDUCTION 1-Piece: OYes @No
Pump Required: @Yes ONo OMay Be Required
Nitrification Field 1 2 0 0
Sq.ft. Pump Tank: 1 0 0 0 Gallons
No. Drain Lines 3 1-Piece: OYes @No
Total Trench Length: 3 0 0 ft GPM—vs— ft. TDH
Trench Spacing: — Feet O.C.
9 Onches O.C. Dosing Volume: Gallons
Trench Width: — 3 ( Inches
Feet Grease Trap: Gallons
Aggregate Depth: inches Pre-Treatment: ONSF OTS-1 OTS-II
Septic Tank Installer Grade Level Required: OI Oil 0111 OIV
Donn 9 of Z
CDP File Number 1610$3 -2 County ID Number. 5861-62335-01
� r
❑ Open Pump System Sheet
Repair System Required:@Yes ONO ONO, but has Available Space
epair System
Trench Spacing: 9 Q Inches O.C.
*Site Classification: Provisionally Suitable — Feet O.C.
Trench Width: Inches
Design Flow: 3 6 — 3 Feet
Aggregate Depth: �
Soil Application Rate: 0 _ 3 inches
Minimum Trench Depth: a 4
*System Classification/Description: Inches
TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Minimum Soil Cover. 1 a Inches
Maximum Trench Depth: 3 6 Inches
*Proposed System: 25%REDUCTION
Maximum Soil Cover. a 4
Nitrification Field -1 a 0 0 Inches
Sq.ft.
No. Drain Lines *Distribution Type: PUMP TO GRAVITY
3
Total Trench Length: 3 0 0 ft. Pump Required: @Yes ONo OMay Be Required
Pre Treatment: ONSF OTS-1 I OTS-II
*Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
*Permit Conditions
The issuance of this permit bythe Health Department in no way guarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements.
This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit,not
to exceed five years,and may be issued at the sane time the Improvement Permit Issued(NCGS 130A-336(b)J If the Installation has not been
completed during the period of validity of the Construction Permit,the Information submitted In theapplication for a permit or Construction
Authorization Is found to have been Incorrect,falsified or changed,or the site is altered,the permit or Construction Authorization shall become
Invalid,and may be suspended or revoked(.1937(g)).The person owning or controlling the system shall be responsible forassuring compliance
with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance,monitoring,reporting and repair.
(1938(b)).
Applicant/Legal Reps. Signature Required? Oyes ONO
Applicant/Legal Reps. Signature- Date:.
*Issued By: 2140-Nations,Robert Date of Issue: , 0 9 al 7 a 0 1 6
Authorized State Agent: Malfunction Logi OYes
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.*
Page 2 of 3
CONSTRUCTION AUTHORIZATION 161083 -2
Davie County Health Department CDP File Number:
210 Hospital Street 5861-624335-01
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 0 9 / ,27 / 2 0 1 6
Q Inch
Drawing Drawing Type: Construction Authorization Scale: , QBlock
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I I PIT s�
CONSTRUCTION AUTHORIZATION
Davie County Health Department '
210 Hospital Street CDP File Number. 1610,83-2,
61083-2
P.O.Box 848 5861.62.4335.01
Mocksville NC 27028 County File Number:
Date: ,0 9 / 2 7 / 2.0 1 6
Click below to Import an Image from an external location: Drawing Type:Construction Authlorization
(330)133-011 W JV aX t330)/33-1b6U
B�EEI 753�//c 8a
App a on or; :I rte Evaluation/Improvement Permit !1 Authorization To Construct(ATC) I"oth
Type of Application: ""w System 1.1 Repair to Existing System I lExpansion/Modification of Existing System or Facility
IMPORTANT*"THIS APPLICATION CANNOT BEPROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Rcfer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Namev/Goe=� NG Contact Person
Address -!JJiE' Home Phone
City/State/ZIP - G = C. 7Z uslness Phone X56- 7<1V-6 5 ;Z
Email Email:
Name on Permit/ATC if DIIYeriat than Above
Mailing Address ,TAons ep City/State/Zip
PROPERTY INFORMATION *Date House/Facili Corners FlaggedG
NOTE: A survey plat or site plan must accompany this application. Included:;:Site Plan r l Plat(to scale)
(Permit is y4lid fgr 60 mo the with site plan,no expiration with complete plat.)
Owner's Name `/�d�Lrc,✓ /ll��,�ys' �i7���.yy ZWe- Phone Number
Owner's AddressD ,P City/State/Zlp Z S% /t/ �• 7loY—
Property Address ' �+ - City}�DlirFrt/C�
Lot Size A Z V fTax PIN# C7�000-DO-USZ
Subdivision Name(ifa,J�plicable) Secti n/Lot#
Direction 'Ib Site: /SS' 7116Ja,7 r
If the answer to any of the following questions is" es",supporting dociynentation must be attached:
Are there any existing wastewater systems on the site? _YesVjN(o
o �hn�� -��
Does the site contain jurisdictional wetlands? _Yes / t6Are there any easements or right-of-ways on the site? _Yes 7,No
o lanes, /V 0� � vQ
Is the site subject to approval by another public agency? Yes
Will wastewater other than domestic sewage be generated? Yes o
IF RESIDENCE FILL OUT THE BOX B W
?People - 2- _ . #Bedrooms . •#Bathrooms Z Z Garden Tub/Whirlpool `Kes [;No
Basement: ! !Yes !Zo Basementlum mg: Ayes ivwo
i
IF NON-_RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/business Total Square Footage of Building #People
inks #Commodes #Showers #Urinals
Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: #Seats
Type system requested: Conventional 1"JAccepted 01nnovative I(Alternative ElOther
Water Supply Type:VC:ounty/City Water New Well !'iExisting Well ;:Community Well
!
Do you anticipate additions or expansions of the facility this system is intended to serve?I.!Yes VNo
If yes,what type?
This is to certify that(fie information provided on this application is true and correct to the best of my knowledge. I understand that
any permits)or ATC(s)issued hereafter bre subject to suspension or revocation if the site is altered,the intended use changes,or if
the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative
of the Davie County Health Department to conduct necessary Inspections to determine compliance with applicable laws and rules.
I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging
or stakin house/facility location,proposed well location and the location of any other amenities.
Site Revisit Charge,
roperty owner's or owner's 1 al representative signature 1-r'
Date(s).-
Client
ate(s): 93Client Notification Date:-/
C /Z '39Ha V1909669CE 'auI 'S•zepTTnE AaxEw wa Tb:ZO 9T0�"�jy'_
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Lot 1 PS 11 PG 371
Lot 2
- PB 11 PG 371
FIN:566M4335
Parcel ID:E700000052 m
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Juney Beauchamp Road
20'Paved Proposed Layout For
80'right-ofas per plot
Prepared BY: Taylor Moore
BOry�kodA. C-23411 Skylark August 18,2016
Pfafttonm,N.C.27040 1 Inch■00 feet
338-9221335
336422.4624 Fax
£ /£ -aE)Vd T7T9O9669££ 'DuI 's29pTTng daxuys pqd TV:ZO 9TOZ'LT'bng
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Lot 1 PB 11 PG 371 Lot z
PB 11 PG 371
PIN:5861-624335
Parcel ID:E700000052 N
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Garage House
33.3'
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In
L=139.82'
edge wp„.,.r R=723.80' _
Juney Beauchamp Road
20'Paved Proposed
60'right-of-way as per plat p Layout For
Prepared By: Taylor Moore
Autry-Abernathy,PA. C-2341
6601 Skylark Road August 16,2016
Pfafftown,N.C.27040 1 inch=60 feet
336-9224335
336-922.4624 Fax
' ,IMPROVEMENT PERMIT For Office Use only
*CDP File Number 161083- 1
Davie County Health Department
County ID Number*5861-62-4335-01
t- 210 Hospital Street
P.O. Box 848
Evaluated For. NEW
Mocksville NC 27028 Township:
Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID UNTIL: 10/1712019
*NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit.
fAddress:
nt: JHMJ Enterprises, LLC r
perty owner: Scott Kimber Beauchamp
895 Ridge Gate Drive dress: 153 Longwood Drive
Lewisville Y: Advance
ip: NC 27021 State2ip: NC 27006
#: (336) 399-3898 Phone#: (336) 399-0398
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
Juney Beauchamp Rd
Advance NC 27006 Directions
Structure: SINGLE FAMILY Hwy 158, Right on Juney Beauchamp Rd, Property
#of Bedrooms: 4 on left just before Baltimore Rd.
#of People:
'Water Supply: PUBLIC s
System Specifications
Initial System
"Site Classification: Provisionally Suitable
Minimum Trench Depth: a 4 Inches
Saprolite System? OYes @No Maximum Trench Depth: 3 6 Inches
Design Flow: 4 8 0 Septic Tank:
1 0 0 0 Gallons
Soil Application Rate: 0 a 1-Piece: OYes QNo
Pump Required: OYes (D No OMay Be Required
'System Classification/Description:
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons
LESS)
*Proposed System: 25%REDUCTION 1-Piece: OYes ONo
Repair System Required:0 Yes ONo ONO, but has Available Space
Repair System
*Site Classification: Provisionally suitable Minimum Trench Depth: a 4 Inches
Soil Application Rate: 0 - 3 Maximum Trench Depth: 3 6 Inches
*System Classification/Description:
Pump Required: ®Yes ONo O May be Required
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR
LESS)
*Proposed System: 25%REDUCTION
Page 1 of 3
CDP,File,Number 161083 - 1 County ID Number: 5861-62-4335-01
*Site Modifications
El Open Fill Sheet
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
7
*Permit Conditions
The issuance ofthis permit bythe Health Department in no way guarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements.
7
Site Plan ""provernent Permit shall be wild for 5 years from date of Issue with a site plan(means a drawing not necessarily drawn to
O scale that shows the existing and proposed property lines with dimensions,the location of the facility and appurtenances,the
site forthe proposed Wastewater system,and the location ofwater supplies and surfacewaters).
Plat The Improvement Permit shall be valid without expiration with plat(means a property surveyed prepared by a registered land
O surveyor,drawn to a scale of one inch equals no more than 60 feet,that Includes:the specific location of the proposed facility
and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters. Plat
also means,for subdivision lots approved by the local planning authority and recorded with the county register of deeds,a copy
of the recorded subdivisions plat that is accompanied by a site plan that is drawn to scale).
The Department and Local Health Department may Impose conditions on the issuance and may revoke the permits for failure of
the system to satisfy the conditions,the rules,or this article This permit is subject to revocation If the site plan,plat or intended
use changes(NCGS 130A-335(f)).The person owning or controlling the system shall be responsible for assuring compliance
with the laws,rules,and permit conditions regarding system location,installation,operation,maintenance,monitoring,
reporting,and repair(.1938(b)).
Applicant/Legal Reps. Signature Required? O'Yes ONO
Applicant/Legal Reps. Signature: Date: /
"Issued By: 2140-Nations,Robert Date of Issue: 1 0 1 7 x 0 1 4
OV
Authorized State Agent: ����-, G
OCreate CA?
01-land Drawing Oltnport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
_.. . . —1.1.11.
Davie County Health Department CDP File Number: 161083 - 1
I 210 Hospital Street
County File Number: 5861-62-4335-01
P.O.Box 848
Mocksville NC 27028 Date:
Q Inch
Drawing Drawing Type: Improvement Permit Scale: OBlock
QN/A ft.
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Page 3 of 3
APPLICATION FOR SITE EVALUATIONIIMPROVEMENT PERMIT & ATC
RECEIVED Davie County EnvironmentalHealth RECEIVED
P.O.Box 848/210 Hospital Street
Date: Mocksville,NC 27028
(336)753-6780/Fax(336)753-1680 SEP 3 0 214
Application For: Site�valuation/Improvement Permit ❑Authorization To Construct (ATC) E3 `--
BoDG
Type of Application: f�New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IMPORTANT** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name ��H M 3 EMTFRpzS C-5 E,L C Contact Person &AIITh.QapAILY ATr Rr 7
Address 89 S R%OGE &TE 2�2.wE Home Phone $31,-391 .08q6
City/State/ZIP LCW1:5Vt" , NG 2'102-$691 Business Phone 331---1-1-7 -oa'1S
Email L1rGn�aodr�'f e4 51��rnatl.Gam
Name on Permit/ATC ifDierentthan Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Fla ed a- -
NOTE: 'A survey plat or site plan must accompany this application. Included: ❑ Site Plan R'Plat(to scale) 4.
(Permit is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name_ SCorr klItnC-K BCAV04AMP Phone Number_319 5-634
Owner's Address_ 153 Ldmawoofl ott,ve, City/State/ZipApVA)/U t y< 110A
Property Address Juin REAVaVMP Qay D
Lot Size 1.233 Aut<6 Tax PIN# VA16 Ste-1624 335
Subdivision Name(if applicable) _Seo1, ejmaM &hvWA(Af, Section/Lot#
Directions.To Site: ubjy . 1S8 '�cat,� 40 JVlaay 8EAVG4ATAV piteray mo tgpr APP(lc� WArKuy
(T$Od MOM I A/['E�EL�a,J OIC J 1� � � �A tl G�� P 1,1�1'1 t 2 ALTiv CNC— O&10%
Specify Problem Occurring:
IF RESIDENCE FILL OUT THE BOX BELOW
#.People #Bedrooms _ #Bathrooms 3 Garden Tub/Whirlpool ❑Yes' KNo
Basement: gVes ❑No Basement Plumbing: ff1 es ❑No
IF NONRESIDENCE FILL OUT THE BOX BELOW
Type of facility/Business Total Square Footage of Building #People
# Sinks ' #Commodes #Showers - #Urinals ;
Estimated Water Usage(gallons per.day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY:: # Seats
' Type system requested: 9Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: VCounty/City Water ❑ New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve?❑ Yes RNo
If yes,what type?
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that
any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use charges,or if
the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized Representative
of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules
I understand that I am responsible for'the proper identification and labeling of property lines and corners and locating and flagging
or staking the hou facil' location proposed well location and the location of any other amenities.
Property owners or o is gal representative signature Site Revisit Charge
Date(s):
Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account# Ip { O Q 2
Revised 11/06 Invoice 9
} � a
je
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section' t
Soil/Site Evaluation
j
APPLICANT INFORMA110N jPiOPERTY I F IO
- !
` Jtuie Beauchamp Road
1'JHMJ,Enterprises,LLC y j
eBrant:'Godfrey Lot# 1
336.399 0398 " i
r -- - - - - - 1:233 Acres
Water Supply: On- ile Well Community blic � A
Evaluation By: Aug rBoring Pit / ut
r
FACTORS1 2 3 5 6 .
Landscape position 7
Slope% ( i
HORIZON I DEPTH
Texture group
Consistence
°.Structure P
Mineralogy
HORIZON II DEPTH
Texture group
Consistence !
! Structure
Mineralogy ! ! I
HORIZON III DEPTH I ( !
Texibre group, 1
- ',Consistence
Structure ! }
Mineralogy
HORIZON IV DEPTH
Texture groupj !
Consistence 4
Structure }
-.Mineralogy
SOIL WETNESS [ 1
RESTRICTIVE HORIZON ( }
SAPROLITE.
CLASSIFICATION n
LONG-TERM ACCEPTANCE RATE O 1 }
SITE CLASSIFICATION: / - EVALUATION BY: 'r(I �M-
}
LONG-TERM ACCEPTANC RA E: _ OTHER(S)! PRESENT:i
I REMARKS:
LE END I
I andscane Position {
R-Ridge S -Shoulder L-Linear slope FS-Foot slope N-Nose slope] r
CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H Head slope { '
Textutu'
S Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt j
SICL-Silty clay loam SII -Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay I
CONSISTENCF.
Moist
4.
VFR-Very friable FR-Ftable FI-Finn VFI-Very firm EFI-Extre ely fain
NS-Non sticky SS-S1iglitly sticky S-Sticky VS-Very Sticky
! NP_Nonplastic SP-Sligkly plastic P-Plastic VP-Very plastic
Structure }
SC Single grain M-Massive CR-Crumb GR-Granular ABK-Ang'lar blocky
SBK-Subangular blocky L-Platy PR-Prismatic }
r
Mineralogy
1:1,2:1,Mixed j s
Nota
i . 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),PS6rovisionally suitable),U(unsuitable) !
TTAT T - ----------