520 Juney Beauchamp Rd Lot 3. DAVIE COUNTY HEALTH DEPARTMENT //� _ /� o
{ Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #:
990000764
Tax PIN/EH #: 5861-52-1223
Billed To:
James Bailey
Subdivision Info:
Reference Name:
Jeff Bailey
Location/Address: Juney Beauchamp Road -27006
Proposed Facility:
Residence
Property Size: 2.54 Acres
**NOTE** This Nprov3ement/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 #People_ #Bedrooms _�� #Baths
Dishwasher: Garbage Disposal: ❑ Washing Machine: 2< Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply L'10 Design Wastewater Flow (GPD) C��� Site: New Repair ❑
System Specifications: Tank Size�� GAL. Pump Tank GAL. Trench Width ��4 Rock Depth Id Linear Ft.���
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED El
FINISHED GRADE. ****NOTICE: Contact a representative of the Davi
system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day c
Environmental Health Spec
DCHD 05/99 (Revised)
,TER RISER(S) IF 6 K BELOW
h Department for final inspection of this
Telephone # is (336)751-8760.****
Date:
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #:
990000764
Tax PIN/EH #: 5861-52-1223
Billed To:
James Bailey
Subdivision Info:
Reference Name:
Jeff Bailey
Location/Address: Juney Beauchamp Road -27006
Proposed Facility:
Residence
Property Size: 2.54 Acres
ATC Number: 2321
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 Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature:
Date:
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.
07
cA"r
0
Septic System Installed By:
a
Environmental Health Specialist's Signature: Date: P
DCHD 05/99 (Revised)
APPLICATION FOR WE EVAWATION/IMPROVEMENT PERMIT & ATC Q � � IFTV
Davie County Health Department S
Enfdnanmentel Health Sa fon
L.O. 8dl8/210 Hos tel Street
/U % e1 �1�` �G� �ey Peoz
Mackavillo, NC 27026
(336) 751-8760
***nW01RT7INT*** THIS APPLICRTION Calm= BW PR=StIWD muses ALL Tisa REQUIRED
IN F4WION IS PROVIDED. Refer to the INrOR1401011 BULLETIN for instructions.
1. Now to be Billed
Nailing Address
Cttx/state/s:p
Z.
3.
s.
HEALTh
rle V % Contact Toon <<o��i'I f L
d D Business Phone
Nan* on Permit/ATC if Different then Above LO ,
Waiting Address A
✓ Cit. ip
sowers
Application fors81te swaluation �Isap ement Persit/l►TC
System to services X Bouse 0 Mobile Home 0 Business 0 Industry
0 Other
0 Both
s. If Residence: i People E Bedrooms # Bathrooms :>9
Dishwasher a Garbage DisposalKrlaehing Naobine Baaement/Pl:sbing 13 sasemant/No Plussbin
6. If Business/Indnatsy/Other: specify type t# People i sinks
# Commodes ; ahowere 4 urinals # Nater Coolers
Ir rWD8ERVICZ: () Seats Estimated Water Usage (oanons per day)
7. Type of Mater oupply: County/City 0 Well 0 Community
9. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes ffio
If yes, what type?
***IMPORTANT*** CUENE'S MUSTCOH-Pr-F—M, ra E®F's1�np wn ;+C ; C„ ri u�irG-Rhi/►ION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITIRD by the client with THIS APPLICATION.
Property Dimensions: -11 5V 141-6
Tax 0111ce PIN:
5�' / -57:2
Property Address: Road Name - & / Pi914
City/Zip
If in a Subdivision provide information, as follows:
Name:
WRITE DIRE//CnONS (from Mocksv(lle) to PROPERTY:
ffST Dom/ ZS7 -
.p Ul/Y/e/ ✓
Section: Block: Lots Date Property Flagged: !�2,9
This Is to certify that the information provided Is correct to the best of my knowledge. I understand that any permit(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 am responsible for all charges incurred from
this appUcadon. % hereby, give consent to the Authorized Representative of the Davie County Health De sa ent
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine the site suitability.
DATE -�/,!� "/ SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE P (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
I Date(s):
Client Notification Date:
I EAS:
Revised DC® (07/99)
Account No. 2 ,!
Invoice No. '9"
5�
(I -
------
INDEXED ON5. 1.16
ees
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This map is for PERC TEST
and BUILDING PERMIT purposes
3239
only. The Davie County
Tax Administrators Office
GnBZ
assumes no liability for any
information contained an this map
2
IND ED ON6861.19
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COUNTY -ID: E70000005201
ChA
September 01, 1999 3:55 PM
ChA
Parcel Identification Number
5861m52-1223
Ms D
1 11
1
APPLICANT INFORMATION
Account #: 990000764
Billed To: James Bailey
Reference Name: James Bailey
Proposed Facility: Residence
Water Supply:
Evaluation By:
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
PROPERTY INFORMATION
Tax PIN/EH #: 5861-52-1223
Subdivision Info:
Location/Address: Juney Beauchamp R ad -27006
2.54 Acres Date Evaluated: d
Property Size
On -Site Well Community
Auger Boring Pit
Public 1/
Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope % L
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH 3
Texture group
Consistence
Structure 5-A !C Alb !' t
Mineralogy
HORIZON III DEPTH'
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE ,
SITE CLASSIFICATION: /05
LONG-TERM ACCEPTANCE RATE: r r
REMARKS:
EVALUATION BY: ! X�`Z
OTHER(S) PRESENT:
LEGEND
Landscape Position
R - Ridge IS - 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)
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MENEM CMEMEMEMENNENMEMEME
...............................
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DAME COUNTYHEALTH DEPARTMENT. -
ENVIRONMENTAL HEALTH SECTION
P. O. Box 848/210 Hospital Street
Courier #09.40-06
Mocksville, NC 27028
Phone #: (336)751-8760
September 21, 1999
Mr. James C. Bailey
1162 Beauchamp Road
Advance, NC 27006
Re: Site Evaluation/Juney Beauchamp Road
Tax Office PIN: #5861-52-1223
Dear Mr. Bailey:
As requested, a representative from this office visited the aforementioned site on
September 20, 1999. Based upon the information provided on the Application for Site
Evaluation and after an evaluation was completed on the site, the site was found to be
provisionally suitable for the installation of an on-site sewage system.
Before an Improvement Permit/Authorization to Construct can be issued the appropriate
application must be filled out and the house/mobile home location staked off.
If you have any questions, please feel free to contact this office.
Sincerely,
J&*t re gv4eA -
Robert B. Hall, Jr., R.S.
Environmental Health Specialist
RH/mp
Enclosure(s)
ti
W {
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1 l v
IM
�1 100 0 100 200 300 Q
., -
GRAPHIC SCALE - FEET c
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FOR AIVE S �' R. o oo n Q)
FOR n. =R_Y iti�IKR 1 i�\ n
.SCR' TOWNSHIP COUNTY STAT DA E- i n O O
N
C.
Uo�N C W ani
LO>N J N
RICHARD HOWARD JOB NO.
SURVEYING — O Z L)�C\,
-
P.O. Box 276 ADVANCE,N.C. 919-998 5398 '3C'�"" N
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t '! APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMITR
D1LR,
0 I
Davie Count Health Department 0 ' v Environmental Health Section NOV 61993
J P. O. Box 665
Mocksville, NC 27028 --""—-
1. Application/Permit Requested By —7 'i y t�Q L v , ,_affi 19 T f
Mailing Address 4 JZ2 G b"\\1-, MNk� S",r• Lo 1&3S-%0 -Sl�t_EM Ill C, Z-7 I Z7
Home Phone J Sig--SQ 7 Business Phone '9a? \3$3
2. Name on Permit if Different than Above `
3. Application/Permit for: , General Evaluation ❑ Septic Tank Installation
4. System to Serve: LTJ House ❑ Mobile Home. ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision �"J Section Lot #1-P
Basement/Plumbing
No. of People 5lob .�IryYr1r3" �� �d� _❑ Basement/No Plumbing
No. of Bedrooms `'t— n _ ZL Washing Machine
No. of Bathrooms� V tE'bishwasher
Dwelling Dimensions Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: Public ❑ Private ❑ Community
8. Property Dimensions Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No
If yes,what type?
'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property: _
Ok
This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurred from this application.
tt l� l5 � ane�7—�
DATE SIG ATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
[and
ECK ONE: 2�1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
ked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
ve consent to the authorized representative of the Davie County Health Department to enter upon above described
cated in Davie County and owned by
all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
al system.
DATE SIGNATURE
DCHD(12.90)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation l/ /
NAMEi��7`'/��" DATE EVALUATED /` ` 2
ADDRESS PROPERTY SIZE G 2
PROPOSED FACIILTY
LOCATION OF SITE
,
Water Supply: On-Site Well Community Public l�
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position .L ,L
Slope Z
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH O t
Texture groupC
Consistence i
Structure L /G
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATEI I
/
SITE CLASSIFICATION: EVALUATED BY: <�
LONG-TERM ACCEPTANCE RATE: .� OTHER(S) PRESENT:
REMARKS:
LEGEND
Landscape Position
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(01-901
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..................................................................
Davie County NealtFr De artment
• Naltir Aen
and .�fvme e y cy ,
210 HOSPITAL STREET/P.O. BOX 885
MOCKSVILLE.N.C. 27028
PHONE:(704)834.5985
November 18, 1993
James & Beverly Martin
4122 S. Main St.
Winston—Salem, 27127
Re: Site Evaluation/2.5 Acres
Juney Beauchamp Road
Martin Subdivision File
Dear Mr. & Mrs. Martin:
els requested, a representative from this office visited the aforementioned
site on November 17, 1993. Based upon the information provided on the
application for a site evaluation and after the evaluation was completed, the
site was found to be provisionally suitable for the installation of an on—site
sewage disposal system.
If you have any questions, please feel free to contact this office.
Sincerely,
WgIx s
Robert B. Hall, Jr . , R.S.
Environmental Health Section
RH/wd
Enclosure
cc: Jesse Boyce, Zoning Officer
• .,�' ' ' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department 7N70V w
Environmental Health Section
J-� P. O. Box 665 _ .»...-,.......
Mocksville, NC 27028
1. Application/Permit Requested By Do Ad A L T— GJ IF C Lt S 1-?
Mailing Address 0? O / A % oc-
Home Phone Business Phone
2. Name on Permit if Different than Above
3. Application/Permit for: neral Evaluation ❑ Septic Tank Installation
4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision /,2744t. Section Lot #
❑ Basement/Plumbing
No. of People �c� Basement/No Plumbing
No. of Bedrooms tl,-Washing Machine
No. of Bathrooms 0-�01s
1'hwasher
Dwelling Dimensions L►�'Uarbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: Public �O� ❑ Private ❑ Community
8. Property Dimensions o y OOSewage Disposal Contractor AJ
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes P-wo
If yes, what type?
'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property: r
P P � L( n L C �
This is to certify that the information provided is correct to the best of my knowledge, and I understand 1 am responsible for all charges
incurred from this application.
DATE ¢� � $
�(�.tx�C,PATUR!l Y 3
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: [--] 1. 1 OWN the property. Liz. I DO NOT OWN thJe
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the own
I hereby give consent to the authorized representative of the Q�vie County Health Department to enter u on ab
property located in Davie County and owned by SWE-s Ft �1 (,�V�—� L�j1�T�
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage
and disposal system.
ri 13 (9s
DATE SIGNATURE
DCHD(12.90)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME i l �''/ DATE EVALUATED h� -
ADDRESS PROPERTY SIZE e�'�i/� ���S
PROPOSED FACIILTY LOCATION OF SITE . .D�'/1�1/'!/h��i✓
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring j/ Pit Cut
FACTORS 1 2 3 4
Landscape position
Sloe %
HORIZON I DEPTH << J/�r
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture groupG
Consistence ell
Structure
Mineralogy / A
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION 7t I
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: a EVALUATED BY: �
LONG-TERM ACCEPTANCE RATE: `� OTHER(S) PRESENT:
REMARKS:
LEGEND
Landscape Position
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(01-901
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• Davie County Nealtlf Department
and .dome Nealtir .fyency
210 HOSPITAL STREET/P.O.BOX 665
MOCKSVILLE,N.C. 27028
PHONE$(704)634.5985
November 18, 1993
Donald & Lisa Richardson //Yw'/%n/
201 Mayfield Dr.
Winston—Salem, 2710 +
Re: Site Evaluation/2.0 Acres
Jamey Beauchamp Road
Martin Subdivision File
Dear Mr. & Mrs. Richardson:
As requested, a representative from this office visited the aforementioned
site on november 17, 1993. Based upon the information provided on the
application for a site evaluation and after the evaluation was completed, the
site was found to be provisionally suitable for the installation of an on—site
sewage disposal system.
If you have any questions, please feel free to contact this office.
Sincerely,
Robert B. Hall, Jr. , R.S.
Environmental Health Section
RH/wd
Enclosure
cc: Jesse Boyce, - Zoning Officer