122 Meadows Edge Drive Lot 24DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990002436 Tax PIN/EH #: 5871-61-5455.24 DB
Billed To: Darren Burke Constr. Subdivision Info: Meadows Edge Lot # 24
Reference Name: Location/Address: Beauchamp Rd -27006
Proposed Facility Residence Property Size: see map
ATC Number: 4010
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, Sectio a Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTE.CTI, IS VMD FOtR,Ei PERIOD OF FIVE YEARS.
Environmental Health Specialist's
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
Z_ I given period of time.
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
10
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
5 _9 I,/
5871-61-54
Meadows Edge Lot # 24
Beauchamp Rd -27006
,_ V o s
Account #: 990002436 N"In 1014( Tax PIN/EH #:
Billed To: Darren Burke Constr.Ct KUd Subdivision Info:
Reference Name: 10 ,D5 Location/Address:
Proposed Facility Residence Property Size:
ATC Number: 4010
see map
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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 f, t #People L1 #Bedrooms y #Baths 2.S
Dishwasher: Garbage Disposal: ❑ Washing Machine: ET'� Basement w/Plumbing: 171" Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size O• `1'2A-� Type Water Supply L-00TY Design Wastewater Flow (GPD) 145 Site: New 00' Repair ❑
System Specifications: Tank Size 00 GAL. Pump TanklC00 GAL. Trench Width 31--' Rock Depthr� & Linear Ft. 345 ,
Other:`i UIc�IL/a!7U16a`I�(L'S, `1-i:
Required Site Modifications/Conditions: '?�=LL 1j
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this
system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.****
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Environmental Health Specialist's Signature:c--4m! Date: � Os'��ti
DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account M 990002436 Tax PIN/EH #: 5871-61-5455.24 DB
Billed To: Darren Burke Constr. Subdivision Info: Meadows Edge Lot # 24
Reference Name: Location/Address: Beauchamp Rd -27006
Proposed Facility Residence Property Size: see map
ATC Number: 4010
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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 . 0ot)&47- #People L— #Bedrooms L4 #Baths Z - S
Dishwasher: Q'� Garbage Disposal: ❑ Washing Machine: Er— Basement w/Plumbing: Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size 0-72- Ate= Type Water Supply &1 -SW Design Wastewater Flow (GPD) 4?Q Site: New Er Repair ❑
System Specifications: Tank Size 1000GAL. Pump Tank GAL. Trench Width St; Rock Depth 12- Linear Ft.�.p
Other: `7 11Si fZt�Xtc �,3
Required Site Modifications/Conditions: 1*—�T�-t� of ��ie� �'Q 1� �C'F ►Sc" Yu cF t,/.1
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this
system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.****
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Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
i ��{ &0(4 LP>]t
Date: W
Mar 09
05
08:50a Darren Burke Construction 336-778-0436
p.2
Mar
04
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Stale 1 inch = 30 feet
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S 67.61' 125.02'
1 /2" EI R N88 -3:T23 w
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30.64'
S 39"15'50" W
105.73'
298.36' 3/4'
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PATSY CARTER KIGER BYERLY
` \ DB 482, PG 647
a ` PIN: 5871529065, LOT 9065
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3/4" EIP)
PATSY CARTER KIGER BYERLY
` \ DB 482, PG 647
a ` PIN: 5871529065, LOT 9065
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Mar 02 05 00:21a Darren Burke Construction 33G -770-043G p,1
Jun 10 03 11:14a davie county envhealth 336 751 8786 p.2
APPUMION FUlt blit iVALtAT1ON/IMPIZOVEAIENT PLlWI 15 MC
Davie County stealth Depanment
EnrirvnMww1Aw1t t.ScAd ov
P_O_ Boat 848/210 roapital Street
Xaeksville, N,- 27028
(336)7SI-6760
•+*nfPORTANT-** 'J'HIS APPLICATION CAbWT BS PROCESSED ONLESS ALL THE REQUIXW
XUFORMATION IS PROVIDED.
Refer to the INFORMATION BULLETIN for iinatructiono.
1. Nose to be 8111.4ZJQ/
'L�C'
Nailing Addreaa C,
Ay)�4L,fe Howe YRone
city/Stat./zip
, �- • 7L'/ ;I ausioesa Mean
1. Haan en posit/ATC It oifte—t than Above
Halling Addr.aa
City/state/zip
3. Application For, '13 ito :1raluation aprovasont Permit/ATC ❑ Both
4. sister to sec+ic.c-OOU9e
D Mobile Hama D Duaiacba ❑ Iadni;Lry 0 Other
S. type system raquoeteda 13 coov.ationsl Q cowesitional modified ❑ lowovativ.
6. If Resistance. i People
•-7 _ Y Bedrooms • a 112throoms
.�tlbl alurasher ❑wrbag. Dlapraa`2-T— p lfscbiaeaeeent/Plumbiog ❑tiaseacnt/++o rlvsbiMJ
7. li ou.iae.s/Industry /otb.r:
verity typoa P.opla a Sinks
s Cusaadea a -+bore[. - I Urinals Y mater CooJera _
IB FOODSERVICE; # Seats. Estimated Water Usage toal3on. per day)
1. Type or water auyplTs ❑ 43ty/City D well ❑ cQuwa—ity
P. Do you aoticipato additions or expansions of the facility !lal4 system is iulcudcd to serve? ❑ Yrs
lryes,what type?
My -
7 -29 - 0 Ya
'•"/AUDRTANT*** CL1rW-SMUSrC0AfPLETE 1-1
THE KrQUIRED PROPEIVTY INFORMATION RL011'ftA
BELOW, other a PLAT or SIM PLAN JOUST BE SUO IITTED by the client with TlitS APPWCATION.
1'roprtfy Dimensions: yt�v1 15 �r}y WRITE DIRECF[ONS (rro., ntorksratr) t. 1•RU1.6;IL'rl
Tax Office PIN: 17____
Property Address: Road Name
Citymp
If in a Subdivision prtwide iaferma-ion, as follows:
Section: Gloek: Let: Date kerac corneas (Is ggcd: ' • l7 O h�'
3aok 0 1413
This is to certify that the information provided is correct to the best of my kumviedge. I understand that any perotit(s)
issued hereafter in subject to swpcusion or revocation. if Wo site pians or intended use change, or if the information
submitted in this application is fnlsira,d or chanted. I, also, underslnnd that I awn responsible for off charres biaure i frnnr
psis application_ 1, hereby, give consent to the Authorized Represtatativt of the Davac aunty 11ral n Ucparttnu+t
to enter upon above described property located in Davie County and owned byeA44 zX !, ......_ .... .__. .
to eouduct all testing procedures as wcessary to determine the site suite
DATE A - 0 1�1 SIGNATURE
THIS AREAWAY BE I=D FORDRAWING YOUR SIZE PLAN (luclude all oI the follotviut: Existing and propused
pruperly Ilea and d4umSi=6 structures, setbacks, and septic tocatioas).
Site Revisit ChuiZe
Datc(s)-
Client Notification Date:
ERS:
Signgivcn AccouutNo.
Revised DCiID (0110] I>lvoiec No. f G
�p �CEE W�
1!,='�RF50
'1'Llc
ENVIRONMENTAL HEALTH
DAV'IE COIATY
n0N 1:011 SITE L'VALUATION/lAII'1IOVUILNT fL1011T & ATC
Davie County Health Department
EnY%rOn/IlentB/Hea/t/1 Section
P.O. Dox 848/210 hospital Strect
Mocksville, PTC 27020
(336)751-0760
* * *1NPORTANT* * * THIS APPLICATION CANNOT LIE' PROCL'SSis'D ULILLSS ALL THE REQUIRED -
IIIFORMATION IS PROVIDED. Refer Lo L•ho INFORMATION DULLETIN for inoLl:uctionu.
Jade Associates II, LLC Alan Jones
1. )lame to be Dillcd Con Lac L• 11craon
Mailing Address Post Office Box 4062 Ifonlc 1'hunc
City/,talc/GIP llucinuSe Thune
tlinston-Salem, NC 27115-4062 (336) 759-9688
2. Ramo on Pc=it/ATC if Different than Above
Mailing Address City/Stale/tip
7. Application For: E3 Site Evaluation ❑ Improvement 13cimiL/A1'C L1 B�L1h
4. 5yatem to Service: ® House ❑ Mobile Home ❑ DuctihlcL•D ❑ 1'lidusLry ❑ OLllcr - _-
5. Type system requested: I�1 Conventional ❑ conventional modified ❑ in(iovaL•ive
G. If Residence: It People 4 II Dedrooins 4 II Bathroom:;2.5
tDiohwasher 6Garbage Disposal ]Hashing Machino CL711a::cwcnL/11lwnbing ❑Uat;cnicnL•/Ile Plumbing
7. If Dusincss/Industry /OLhor. verify type Il People 11 inls
tl Commodes 11 Showers 11 Urinalo 11 WaLcr Coolers
IF FOODSERVICE: If SeaLs Estimated waL'e1 UDage (gallons per day)
S. Typo of water supply: M County/City ❑ well ❑ Conuuuliityy�tI
2. Do you anticipate additions or C\1):11hS1011J Uf flit Lll'lllty tills S)'StCill IS Jllll'll(ll'(1 (u sl'1.1'c'l ❑ yes DCNo
If ycs, )%•ha( type?
*"IMPORTANT*** CL1LN'fSd1USTCOAfI'LL•'TL:"FlIE lu,-QUIIfL•'D 1'1t01'lilt'11' 1NFORNIA-1-ION RLLtJI?STl-.*D
BELOW. limier a PLAT orS1TE PLAN NUSTQESURA117TED by the clicut widITHIS Al'I'LICATION.
Pruperl)• Diinensiulis: See attached map WRITE DIRLC1•IONS (1'rum Aluchwinr) t(, PRO1 Lat' T:
Tax Office PIN: 11 5871615955 East on Highway 158, turn right onto
Property Address: Road Nanic Beauchamp Road
City/Zip Advance, 27006
11 iM a Subdivision provide infurnintion, as full uivs:
Nal,lc: Proposed Jade Associates
Scctiotl: Bloch: Lot: 24
Gun Club Road and proceed to the end of
the road, turn left -onto Beauchamp Road
and the site is located approximately Wo
rules down Beauchamp Road on the right and
left side of the road.
3/8/04
Date Ilonlc curners !lagged:
This is to certify that file infornhatiou provided is correct to the best of shy )(1101 ledge. 1 understand deft any perrhlil(s)
issued hereafter arc subject to suspension or revocation, if the site plans ul• intended use change, or if file iufurluadun
subini((ed in this application is L•llsilied ur changed. I, also, run/e'rslrrru/!!rn! l uur reg/)urrsiGlc jut rrll chruSes iucurrrrl %tutu
flus upplicariun. I, licrcby, gift Conschht to the Authorized 11cpi•cscII(at1Ye of till' Davie Culutly Ilpaldl De lard) Ln
to cuter upon above described pruperly located ill Davie County and owned by Jade Associates
to conduct all testing procedures a5 neccssary to determine the site suitaby.
DA•flE 3/15/04 SIGNATURE r ✓'71��
TINS AREA MAY BE USED FOR DRAWING'IOUR SITE PLAN (Include all of the fullowhig: Existing and prupuscd
property lines and dinleiisions, structures, se(bnclts, and septic locations).
Sign given
Site Revisit Charge
Datc(s):
Client Notification Date:
Ells:
Arrmmf Nn
"4_"41Tj 1 DILkI10011 . I DF41M.1 ' :: vuI jI
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003105 Tax PIN/EH #: 5871-61-5955.24
Billed To: Jade Associates II, LLC Subdivision Info: Prop. Jade Assoc. Lot # 24
Reference Name: Location/Address: Beauchamp Rd -27006
Proposed Facility: Residence Property Size: see map Date Evaluated: I
Water Supply: On -Site Well Community Public ✓
Evaluation By: Auger Boring Pit Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
L_
Slope %
420
HORIZON I DEPTH
- .
- 3
Texture groupe—
Consistence
Structure
U
Sok
Mineralogy
1
HORIZON II DEPTH
4 0
X731 14
Texture group
C_-}
_<'-, C'1
Consistence
01591
5s5p
Structure
Mineralogy
HORIZON III DEPTH
"5L
Texture group
S'+C.L-
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: r
LONG-TERM ACCEPTANCE RATE:
REMARKS:
LEGEND
Landscaae Position
EVALUATION BY: c� ' �-�A"`'
OTHER(S) PRESENT:
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)