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117 Meadow Brook Court Lot 40• DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 OPERATION PERMIT Account #: 990004019 Tax PIN/EH #: 5874-52-1561 Billed To: E.J. Hanes Construction Subdivision Info: Meadows Edge Lot # 40 Reference Name: Location/Address: 117 Meadow Brook Ct.-27006 Proposed Facility: Residence Property Size: ATC Number: 4756 **NOTE** The issuance of this Operation Permit shall indicate the system described 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 Tank Date J - 30 -66�0 Tank Sizeof o a Pump Tank Size loos STB3i3 System Installed By: Rhodes 3g&h4 Su(j. E.H. Specialis . Date: All I-Nw ItvLl - �b to �oa-C �k. �° e"X-?4- f DCHD 11/06 (Revised) Me DAVIE COUNTY HEALTH DEPARTMENT - - - Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003105 Tax PIN/EH #: 5871-61-5955.40 Billed To: Jade Associates II, LLC Subdivision Info: Pro Jade Assoc. Lot # 40 Reference Name: Location/Address: Beauchamp Rd -27006 Proposed Facility: Residence Property Size: see map Date Evaluated: L` Water Supply: On -Site Well Community Public ✓ Evaluation By: Auger Boring Pit '� Cut FACTORS 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH — Texture groupG G Consistence Structure 1L Mineralogy HORIZON II DEPTH Texture group' G Consistence Structure Mineralogy.' HORIZON III DEPTH Texture group Consistence rJS $ r3 Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION P LONG-TERM ACCEPTANCE RATE fes. SITE CLASSIFICATION: e S 11)0--) LONG-TERM ACCEPTANCE RATE. O''� s-_ 0 •4 REMARKS: EVALUATION BY: ` � m OTHER(S) PRESENT: 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 05/99 (Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH T�y IQ1 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 1 (336)751-8760 Fax # (336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990004019 Billed To: E.J. Hanes Construction Reference Name: Proposed Facility: Residence ATC Number: 4756 Tax PIN/EH #: 5874-52-1561 Subdivision Info: Meadows Edge Lot # 40 Location/Address: 117 Meadow Brook Ct.-27006 Property Size: Site Type-:eB<ew ❑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: # Bedrooms q # Bathrooms2,< # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size 0755 Type of Water Supply: ,BL�ounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow (GPD) q9bTank Size �� GAL. Pump Tank] GAL. Trench Width Max. Trench Depth :2L Roc Ik Depth al&- Linear Ft.44© Site Modifications/Conditions/Other: 1►JSTL,tL p.-� C�lZi��, —rad 2�� Contact the Davie County Envirbnmer 8:30 — 9:30a.m. on the d Environmental Health DCHD 11/06 (Revised) Health Section for final inspection of this system between A installation. Telephone # (336)751-8760. `-133.89' 19 fSnj `— 15�Land oc pe E menCP — r � 41 J � W pp )g$6j' CH E �� I z 0.69 acres 1: i�Ln "t4 0 O /in = uncn OQ N P N W 0-7�5 acres Ln 20' Pubiic N o Droinoge ' 9 -f< Ease ment ,.10.70 i0 0 12 7, 01 ' o � 82', g_38, _----- -�1 s N S 89' 15'57" tilit 10 E , -- t E 137.70 ``--- e do2v )6,89' Control ( Corner- %- r 'ernent f� 145.51' '.'.r., 85. Qo' a ' 6%1. 0 0.s g� V L� 129.42' 134 l��',:� 711 -- CH E S ��.o Cl - 35 O a u, $z 0.70 acres o o o N 0.70 acres f a Iry 37 0.69 acres f 145.51' 113.49, --NB9'14157"W -1355.75'-,- x __. 295.70► F� NCE LINE x f c APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department _ vironmental Health Section fry .O. Box 848/210 Hospital Street D Mocksville, NC 27028 6)751-8760/ Fax (336)751-8786 p � 3 20ti1 Applicat Aite Evaluation/Imp ovem nt Permit Puthorization To Construct(ATC) ❑ Both ***IM ORTANT� ATION ANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFOIA ID a er to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed t-\O.C1e� s�n5kJrUA!0n Contact Person LOge NA e,S Billing Address ay?,"1 W Ca mmeflyt1� ci Home Phone � 1 _ City/State/ZIP t,���ptj SaAem NC a -r 1a -i Business Phone c� ` LA. Name on Permit/ATC if Different than Above Mailing Address A JO` PROPERTY INFORMATION NOTE: A surveyplat or site plan must accompany this application. (Permit is valid for 60 months with sitelan, no expiration with complete plat.) Street Address %-(U-M �O W r06t ity f1CIL- _Tax PIN# 5q -716-7-15'(d Subdivision Name Sectioo Lot Size 1 Directions To Site: 1. lan 1,�n N g,0 I e % . A w_v o 12 4 • r gal hi _nv Date House/Facility Corners Flagged I 10 1dQu -1 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 XNo Does the site contain jurisdictional wetlands? oyes)'No Are there any easements or right-of-ways on the site? XYes ❑No Is the site subject to approval by another public agency? ❑Yes X"No Will wastewater othet than domestic sewage be generated? ❑Yes P&O IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms 14 # Bathrooms rGarden Tub/Whirlpool Yes ❑No Basement: eyes�1No Basement Plumbing: Wes�To 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: Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other Water Supply Type: County/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 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 understand that I am responsible for all charges incurred from this application. 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 on the above described property located in Davie County and owned by E_ .. "Mnp-s Ccc o j ysicAtel'1 . owner's Sign given ❑Yes ❑No Revised 2/06 representative signature Site Revisit Charge Date(s): Client Notification Date: EHS: Account # 'Al Invoice # . E .Eu E DIl �1 'LICATION 1:011 SITE L'VALUATION/lAlfltovaiwr i,ai i17• & xx t 5 2Q04 Davie County Health Department MAREiwirenn1enta/Health 5eCM011 P.O. Dox (34(3/210 HoopiL'al Street ENVIRONMENTAL HEALTH 1•Iocksville, NC 27020 DAVIECOU40 (33G) 751-07GO 1 ***IMPORTANT*** TIIIS APPLICATION CANNOT DE PROCESSED UIILLSS ALL '1 HL R1QUI1tL•'D. .- I INFORMATION IS PROVIDED. Refor to the INFORMATION BULLETIN for illotructiol'lu. Name to be Dilled Jade Associates II, LLC ConLacl' Person Alap Jones Mailing Addresa City/State/'LIP Post Office Box 4062 Itauc Phone Winston-Salem, PJC 27115-4062 Dusinuas I'hulle (336) 759-9688 2. Namo on Permit/ATC if Different than Above Mailing Addreas CiL•y/StaL'c/F.ip __ _.__._._.. .•_._._ _ J. Application For: 91 Site Evaluation ❑ Improvement- Permit/ATC ❑ lluLll g 4. System to Service: ® House ❑ Mobilc home ❑ Duz;inc:, s ❑ Industry ❑ 01;11cr -_ ti 5. Type system requested: I$ Conventional ❑ conventional modified ❑ illnovaLive G. If Residence: II People 4 II Bedroom.- 4 II DaL'liroc)IIL'1 2'5 tDiahwasher LGarbage Disposal nNashing Machino ❑DascmcnL/I'lLu bing ®Da::emonL/no Plumbing 7. If Dusinca5/Industry /other: verify type 0 Commodes 11 Showers 0 People 11 LU10, 11 Urinala 11 WaLcr Cooleru IF FOODSERVICE: 1/ Seats Est'imat'ed Water Usage (gallon, per day) S. Type of water supply: ( County/City ❑ Well ❑ Conuuunity�t 2. Do you anticipate additions or cxl)allsiollS of the f:lL•111(y IlliS 531S(Call iS Ill(ell(le(I (u SCl 1'C'1 ❑ YCS M N1) 117yes, 11'1lat 0'pe? ***1AI1'01MINT*** CLIEN'rSrl1US'TCOAIPLG'1'G'rilL K1iQUIRL'D 1'I(Ol'EK'1'1' INFORMATION I(ISQUES'I.ED BELOW. (;idler a PLAT orSITE PLAN MUSTBESUll187YGD by the clicul rrith'1'IIIS Al'I'l,IG1'I'10(Y. N-uperly Din,cusiuns: T;IX Office I'IN: I/ See attached map 5871615955 PropertyAddress: Road Nalllc Beauchamp Road City/Zip Advance, 27006 Wltl'rl: Ull(LCTIUl`(S (11'1)11( Alucksrille) 11) I'I(UI'lilt'I'1': East on Plighway 158, turn right onto Gun Club Road and proceed to the end of the road, turn left -onto Beauchamp Road If in a Subdivision provide infurnlalion, as 1701101vs: and the site is located approximately tk Nan1C: Proposed Jade Associates r3i 1 es down Beauchar.lp 'Road on the right and left side of the road. 3/8/04 Scclion: Block: Lot: •3-�_ Date home corners Qagged: 0i zEy This is to certify that (lie information provided is correct to the best ol'nly knowledge. I uuders(aud th;l( ani' permit(s) issued hereafter are subject to Suspension or revocaliou, if file site plallS U1' illicllded USe cliallge, Or if the iufurulaliull sub,ni((ed in this applk:ltiall is f;dsilicd Or changed. I, also, 11111ter•strulrl that 1 (1111 1'CSpu11sib1C fur• r111 C/rruSCS ilIC111•rl'd•%rual this application. I, hereby, give consent to (lie AullioriLed Repl'esentalive of Ilse Davie Cuuuly I1cal(ll n Dely•(!! cn to enter upoabove described pruperly lucaled in llaii vie County and owllcd by Jade As ates I , tL� to Conduct all testing procedul'es as necesSary to deleru,ine the Si(C suits ' 3/15/04 � DATE SIGNATURE MIS AREA MAY 13E USED FOR DRAWING YOUR SITE PLAN (Include all of the fullolring: Exisling and prupused property lines and dimensions, structures, setbacics, and septic locations). Ae Site Revisit C11:11•ge Client Nolificatiun Date: EIIS: Sign given ,1" ,,,,..f TJ„