107 Meadow Creek Court Lot 34r DAVIE COUNTY ENVIRONMENTAL HEALTH
• P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751,8760 Fax # (336)751-8786
Account #: 990004348
Billed To: Sonoma Building Company
Reference Name: Rick Tozier
Proposed Facility: Residence
OPERATION PERMIT
Tax PIN/EH M 5871-42-8243
Subdivision Info: Meadows Edge II Lot # 34
Location/Address: Meadow Creek Court -27006
Property Size: 0.74
ATC Number: 4674
**NOTE** The issuance of this Operation Permit shall indicate the system descnbed on the ATC 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.
System Type:_ S.T. Manufacturer s ''`A Tank Date �Zy Tank Size_tA
Pump,Tank Size J q ��
System Installed B' `�'`�' 5 is ' r
y Y� p�
Z
DCHD 11/06 (Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street ll�
Mocksville, NC 27028
(336)751-8760 Fax # (336)751-8786 .
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account M
990004348
Tax PIN/EH #:
587'1-42-8243
Billed To:
Sonoma Building Company
Subdivision Info:
Meadows Edge II Lot # 34
Reference Name:
Rick Tozier
Location/Address:
Meadow Creek Court -27006
Proposed Facility:
Residence
Property Size:
0.74
ATC Number: 4674
Site Type:211'e'w ❑Repair ❑Expansion
**NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A
Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat
or the intended use change.
Residential Specifications: # BedroomsA # Bathrooms 3s# People Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size Type of Water Supply; ounty/City ❑Well ❑CommunityWell
System Specifications: Design Wastewater Flow (GPD)�Vg_oTank Size GAL. Pump Tank GAL.
Trench Widths Max. Trench Depth Z& Rock Depth N A LinearFt.
Site Modifications/ onditions/Other:(o �tozl S tom- L-0
D� ')g' C.0 4TZ=!f
Contact the Davie County nvironmental Health Section for final inspection of this system between
8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760.
2115
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Environmental Health Specialist
DCHD 11/06 (Revised)
4 &P& Jo7 - j5V IS6-7
1}
EAS£kENT& OR RIGHTS—OF—WAY 6
IECORO PRIOR TO THE DATE OF
•' THIS AMP WHE7HER VISIBLE OR NOT
TITLE SEARCH NOT PROVIDED.
CA'Rp`',
...... •�,,;
p�iiFf MAP
g0? 142001OVEYANCES
4 0 ' - RDATION
a
v
b�S
�Q
00AIM11601
kt�ic
L
-------------------Zie�L
MEADOW BROOK COURT SO' R/W (public)
R/w ---
LOT 33
P8 8 PG 259
-----R/W
LOT. 35
PB''8 PG 259
Re
owl a a
�2
SQs �1�"~�
WAP FOR
SONOMA BUILDING CO.
8
WATER YETER
R/w PICHT-OK WAY i
SCALE COUNTY TDWNSTHP
DATE
PAM RAT$
•
VER 11ATil01F
... ` r4jNR= WATER'
T• 80 DAVIE FARMN OTON
18 WAY 2407
1 : 10.000
O
O
a
INCH FOUND — ^y
BON SET
MONUMENT
E—OVERHEAD POWER LINE
® POWER PCE
PROpFRTY OEsc: LOT 34 eF:IEADOM6 FDCE• phase 2 P8 8 PG 259
PROPERTY LW
•.-- --
® PGWT
(—Yoo
PROPERTY Lim
(not mercy*
NOT WONUWENTEO
WY SEAL. AND SltliAltfRE
CERTIFY THAT THIS LMP IS
THE RESULT OF AN ACTUAL
SURVEY PERFORMED UNDER
MY SUPERVISM
CAE FORESTRY L SU R%CY HC
P.O. BOX 38
WAtlBlkt- Nr- 27373
=/FAX (336) 769-4673
JOB 1
07132
DRAFTED
A B
Zd WdS0:b0 40OZ 8t •FiRW
£L9tb 69L 9sr
•ON 3M3�u AaIic32r!na 3b Wow
moi
X
j uv o/ L 219.19' S
Meadow Creek Court (Public 50' R/w), 2
Control
omer. S 89' 15'57" E 406,89
10 Utilit Easement
79.47' 152.49'
A1 30' Front MBL (typical)
r
P 33
0.72 acres
01 Io,
�4.
0.74 acres :E
30' Rear MHZ (typica
Fim
214.96' L 152.49' 1
x x x ---.r
EARL F. M YER S
DB 112, PG 438
PIN: 5871 41 571 8, L07 5718
wise noted.
ARC
LENGTH
wise noted. A-- 11
21.03
A— 12
46.68'
A-13
46.68 '
A— 14
42.49
�. A-- 15
21.03 '
SITE EVALUATION/IMPROVEMENT PERMIT & ATC
1 2007 Davie County Environmental Health
�� QY P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
ENVIRONMENTAL HEALTH (336)751-8760/ Fax (336)751-8786
DAVIE COUNTY
Application For: Q 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 to be Billed
`�c,, , fr,c,
ti �. ,�, �;. �y
i� �., �� `.-;, (,
Contact Person
Billing Address
PC) calx ,SEL',
��—
Home Phone j
3t,
City/State/ZIP
Vic,; -}c,;.,
Sc,19
Business Phone 5"3t,
-j337
Name on Permit/ATC if Different than Above
Address
City/Sta
PROPERTY INFORMATION *Date House/Facility Corners Flagged 5115107
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
(Permit is valid for 60 months with site plan, no expiration with complete plat.)
Owner's Name So r,b— e" Phone Number 3:16 /24%
Owner's Address Po 2, bl City/St e Zip L) •n5 Iii .,Ike, ..,1
Property Address L City.
Lot Size 'j�/ Tax PIN# %/-qZ� Zq3
Subdivision Name(ifapplicable)ZQaG?o-,>5 J -T Section/Lot# '3-a 3
Directions To Site: iool le.l l _ h �.v c6w,, ,6 -L �,,S ,). J 7, 91-
If the answer to any of the following questions is "yes", supporting documentation must be attached.
Are there any existing wastewater systems on the site?
❑Yes 4SNo
Does the site contain jurisdictional wetlands?
❑Yes2No
Are there any easements or right-of-ways on the site?
❑Yes iRNo
Is the site subject to approval by another public agency?
❑Yes HNo
Will wastewater other than domestic sewage be generated?
[]Yes RNo
IF RESIDENCE FILL OUT THE BOX BELOW
# People # Bedrooms q # Bathrooms _ Garden Tub/Whirlpool in Yes ❑No
Basement: []Yes fffNo Basement Plumbing: ❑Yes KNo
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:. KConventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: ES-County/City Water ❑ New Well ❑Existing Well ❑ Community Well
Do you anticipate additiaps or expansions of the facility this system is intended to serve? ❑ Yes -8,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 I am responsible for the proper identification and labeling of property lines and corners and locating and flagging
or staking the house/facility location, proposed well location and the location of any other amenities.
Property owner's or owner's legal representative signature
Date
Sign given ❑Yes ❑No
Revised 11/06
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account #
Invoice #
EE
rr n (i;
D ,J
: 1 ICATION 1:011 SITE L'VALUATION/141PRUVLAIL•NT I'UU%I1T & 1C1'C
4,+,t,I� l 7110"t Davie County Health Department
Environurcnta/Hea/t/� Section
P.O. Dox 840/210 lfospiLal Street
ENVIRONMENTALHEALTH Mocksville, 1IC 27020
DAVIECOUNTY (336) 751-0760
***XHPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UIILLSS ALL T1IL•" REQUIHLD I
IIIFORMATION IS PROVIDED. Refer to L•ho INFORMATION DULLLTIN for il1rtl:uCLi0na .
Jade Associates II, LLC Alam Jones
1. Name to be Billed Conl'acC PL`rJUn _ _._•.__,• ,
Mailing Address Post Office Box 4062 lioutc 1'honc
City/,talc/ZIP
llinston-Salem, PJC 27115-4062 lluuinc!is Phwtc (336) 759-9688
2. llama on Permit/ATC if Different than Above
hailing Address City/Stale/Zip
3. Application For: M Site Evaluation ❑ Iwpi'ovelnent PeriniL/ATC 17J IJUL'11
4
9. System to service: ® Ilouse ❑ Xobile home ❑ Duf;iIlchD ❑ Industry ❑ Other
S. Type system requested: M Conventional ❑ conventional modified ❑ innovaLivu
G. If Residence: It Peoplc 4 II Bcdroonll� 4 II batI11:00111:, 2.5
Liollwasher InGarbage Disposal KIKashing Machine ❑UacemenL/No Plumbing
7. If nunincas/Industry /Other: verify type It People 0uink.]
11 Commodes 0 Showers It Urinalu 11 WaL•ur Coolcru
IF FOODSERVICE: It SeaL•a Estimated Water Ur'agc (gallona per day)
8. Typo of water supply: In County/City ❑ well ❑ ConunuuityYv
9. Do you anticipate additions or CXp:L11s1011s Uf i11C fal'lhty flits s)'SlClll iS 1lllWldl'(I lu scrvc? ❑ yes Oct Nu
If yCS, What 0-I)C?
***IAII'ORT111YT*** CLILN'rSBIUSTCOAIPLL•'TL•''rllE 1(GQU1l(L•'U 1'1(Ol'L'lc'1'1' IIVhORI1lA'!'lON RLQUES• E'D
BELOW. Either a PLAT or SITE PLAN )UUSTBESUIMMI7'EU by the client rrillt'1'IIIS AI'I'I,1CA'I'ION.
Pruper(y Dilucusiulls: See attached map
'I':lz orrice 111N: fl 5871615955
Property Address: Road Name Beauchamp Road
Ci ly/Zip
Advance, 27006
WRN1* LARECTIONS (I•rom 1lluchsvillc) to PRUI'liRTY:
East on highway 158, turn right onto
Gun Club Road and proceed to the end of ...
the road, turn left -onto Beauchamp Road
1f ill a SubdiVi5i011 provide 1111UCIllation, as follows: and the site is located approximately two
Name: Proposed Jade Associates rules down Beauchamp Road on the right and
left side of the road.
Section: Bloch:: Lot: 34 Datc home curucrs flagged: 3/8/04
This is to certify that the infornimion provided is correct to the best ol'luy lutotisledge. 1 understand that .1113' I)erulil(s)
issued hereafter arc subject to suspension or revocation, if (lie site plans ur iliteuded use change, ur if (Ile infolrula(iun
subnli(led in this application is falsilied ur clanged. I, also) understand thatl am reshunsible fur rill ch« )Ses inc•lnrrrl fruul
this applicatiun. 1, hereby, give consent to (lie Authorized Rcprescu(alive of lite D:lvie Cutill (), 11c:dlll De ).11.111 cnl
to alucr upon above described pruperly loca(cd in Davie County and owlied by Jade Associates 41 , �LG
to conduct all testing procedures as necessary to de(ernline (lie site suitability.
DATE "3/15/04 SICNATURL 'G�H��(�i t!a-✓
TRIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (IJlclude all ul'the fullolvin6: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
D:ltc(s):
Client Notification Date:
LMS:
Sign given
At•rnnnl No
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION
PROPERTY INFORMATION
Account #:
990003105
Tax PIN/EH #:
5871-61-5955.34
Billed To:
Jade Associates II, LLC
Subdivision Info:
Prop. Jade Assoc. Lot # 34
Reference Name:
Texture group�-
Location/Address:
Beauchamp Rd -27006
Proposed Facility:
Residence
Property Size: see map Date Evaluated:
Structure
,
Mineralogy
Water Supply:
On -Site Well
Community
Public t/
Evaluation By:
Auger Boring
PitX,'
Cut
FACTORS
3 4 5 6 7
Landscape position
Sloe %
5Zo
HORIZON I DEPTH
Texture group�-
Consistence
Structure
,
Mineralogy
HORIZON II DEPTH
A ► .
Texture group
Consistence
S
; ,
Structure
Mineralogy1:
l
HORIZON III DEPTH
Texture group
5' C- S
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: 1 '� " Z7" EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: P-3 OTHER(S) PRESENT:
REMARKS:
LEGEND
Landscaae 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 05/99 (Revised)
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