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P161087 Lot 2 SK Beauchamp
IMPROVEMENT PERMIT Forofrceuse only *CDP File Number 161087- 1 ;"J'. Davie County Health Department t- 210 Hospital Street County ID Num be r:5861-62-4335-02 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. Applicant: JHMJ Enterproses, LLC rAdd perty owner: Scott Kimber Beauchamp Address: 895 Ridge Gate Drive ress: 153 Longwood Drive CdY: Lewisville v. Advance StatelZip: NC 27021 State2ip: NC 27006 Phone#: (336) 399-0398Phone#: (336)399-0398 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: 2 Juney Beauchamp Rd Advance NC 27006 Directions Structure: SINGLE FAMILY Hwy 158, right on Juney Beachamp Rd. on left #of Bedrooms: 4 before Baltimore Rd. #of People: *Water Supply: PUBLIC System Specifications Initial S stem *Site Classt Ica ion: Provisionally Suitable Minimum Trench Depth: a 4 Inches Saprolite System? QYes QNo Maximum Trench Depth: 3 6 Inches Design Flow: 4 8 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 0 3 1-Piece: QYes QNo Pump Required: QYes 0 N OMay Be Required *System Classification/Description: TYPE 11 A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: 1 0 0 0 Gallons LESS! *Proposed System: 25%REDUCTION 1-Piece: QYes QNo Repair System Required:®Yes ONo ONo, but has Available Space F epair System Classification: Provisionally Suitable Minimum Trench Depth: a 4 Inches Application Rate: 0 3 Maximum Trench Depth: 3 6 Inches *System Classification/Description: Pump Required: ®Yes ONo Q Maybe Required TYPE IIA.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System: 25%REDUCTION Pagel of 3 J CDP File Number 161087 - 1 County ID Number: 5861-62-4335-02 *Site Modifications ❑ 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 wayguarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. CP 7! Site Plan The Improvement Permit shall be valid for 5years 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 for the proposed Wastewater system,and the location of water supplies and surface waters). Plat The Improvement Permit shall be valid without expiration with plat(means a property surveyed prepared by a registered land surveyor,drawn to a scale of one Inch equals no more than 60 feet,that Includes:the specific location of the proposed facility O and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surfacewaters. 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 platthat 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 subjectto revocation If the site plan,plat,or intended use changes(NCGS 130A-335(%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/Legarreps. Signature: Date: "Issued By: 2140-Nations,Robert Date of Issue: 1 0 / 1 7 / a 0 1 4 Authorized State Agent: OValid without Expiration? 0Create CA? GHand Drawing Olmport Drawing **Site Plan/Drawing attached.** Pana 9 nf'A IMPROVEMENT PERMIT Davie County Health Department CDP File Number: 161087 - 1 210 Hospital Street 5861-62-4335-02 P.O.Box 848 County File Number: Mocksville NC 27028 Date: 1 / Q Inch Drawing Drawing Type: Improvement Permit Scale: QBlock Q N/A ft. L W� 1 � uSl vi' r r� : 'Oed P AP`PLICATIION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC RECEIVED Davie County Environmental Health O , P.O.Box 848/210 Hospital Street DOC -14- NC 27028 (336)753-6780/Fax(336)753-1680 Application For: 'Site Evaluation/Improvement Permit ❑Authorization To Construct(ATC) ❑ Both Type of Application: ©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 A FNTE-"fzas C-5 4 L.LK, Contact Person&ART V.GooO-LY R X Address__ 89 S R%066 GATE 2�ttkjc Home Phone S31,,-3q-1 -439 6 City/State/ZIP LEw1SUtu.6 , NG z'lU2-S6g1 Business Phone 331.--1-1'1 Email br4nt'aod-(r e4 51-d y ry\40.da&) Name on Permlt/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged 16:1-IV NOTE: 6- - NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan 13plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name $CvTT 0-VRE Z 13CAtX cAMP Phone Number 336'344-03lg8l Owner's Address 153 Ldw7woop DawE City/State/ZipApyA1JLE P< 2-1046 Property Address I hur lrnVgVvt P QptD City_Ai& c61 xc Lot Size /•236 .AA110 Tax PIN# ?ART 5$G 162y335 Subdivision Name(if applicable) marl K1MaCK REAVOIA(AP Section/Lot# 2— Directions Directions To Site: WWX 15 : Qt,T1t dAJ $EAvcunmQ _pitspg*t/ o-A1 l.s: T AP1W1MAr«Y ( 5?.-id IMOYr I1✓r4A-9 ,1Xd4 01C 1.11iuk-y _ 6AdGJJ4MP WiPu R ALfly-tOttk- (121%7, Specify Problem Occurring: IF RESIDENCE FILL OUT THE BOX BELOW # People E #Bedrooms a #Bathrooms_ Garden Tub/Whirlpool ❑Yes FMo Basement: P1Yes ❑No Basement Plumbing: 2 Yes ❑No IF NON-RESIDENCE 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: LIConventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: 6kCounty/City Water ❑New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?❑ Yes V`No 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 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 1 am responsible for the proper identification and labeling of property lines and corners and locating and flagging or stakiW the hous /facil-ty location,proposed well location and the location of any other amenities. Site Revisit Charge Property owner's or o r' egal rep esentative signature Date(s): Client Notification Date: Date EHS: Sign given ❑ Yes ❑No Account Revised 11/06 Invoice# i f+ . E DAVIE COUNTY-HEALTH DEPART NT Environmental Health Section Soil/Site Evaluation ' j. /AV, LICANT INFORMATION 1 INEORMATION � I jkM1 Efiterprlses,LLC f Juney Beauchamp Rd F. Brant Godfrey ti Lot#2 f 336`399-0398 k i 1.236"Acres Water Supply: On- ite Well Community blic Evaluation By: Augr Boring Pit ut FACTORS 1 2 3 5 6 7 ^Landsca a position (� ! r� Slope % :. HORIZON i DEPTH Texture group, a•" SC C C Consistence ..Structure-, Mineralogy HORIZON II DEPTH Textureegroup C Consistence w I 'Structure; /L IVlineralo 3 " i ` !•.HORIZON III,DEPTH ! J Texture" ou a Con-sistence Structure: I MmeralogyI i HORIZON IV DEPTH Texture` rou I Consistence Structure k _ Mineralogyi SOIL WETNESS I i RESTRICTIVE HORIZON I I s SAPROLITE i CLASSIFICATION T1 LONG-TERM ACCEPTANCE RATE O• 3 SITE CLASSIFICATION: EVALUATI N BY: LONG-TERM ACCEPTANC 'RATE: OTHER(S)PRESENT: • i r i i REMARKS: LEGEND Landscape Position ! ' R Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose stope;. CC-Concave slope CV-Convex slope T Terrace FP-Flood plain H Head slope S -Sand LS -Loamy sand{ SL-Sandy loam I.-Loam SI-Silt i � . SICL-Silty clay loam SIIr-Silty loam CL-Clay loam SCL-Sandy clay loam SC 'Sandy clay SIC-Silty clay C-Clay I f CONSISTENCE Moist !}E t VFR'-Very friable .FR-Fable FI-Firm VFI-Very firm EFI-Extremely firm NNS--Non sticky SS-SligE tly sticky S-Sticky VS -Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic i Structure SC-Single grain M-M sive CR-Crumb GR-Granular AB -Angular blocky SBK-Subangular blocky L-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 E 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(pnsuitalile) TTA" T - --__- ._-__ ._._ __t l.t•_./Can - . .. -'��"-""' -•^- •� X