127 Brookmead Court Lot 17DAME COUNTY HEALTH DEPARTMENT
» Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990003552 Tax PIN/EH #: 5871-61-5955.17 TR
Billed To: Tate Rice Homes, Inc. Subdivision Info: Meadows Edge Lot # 17
Reference Name: Location/Address: Brookwood Court -27006
Proposed Facility Residence Property Size: see map
ATC Number: 4266
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 .190 wage Trea,Umnt and Disposal Systems). THIS
AUTHORIZATION FOR WASTE R ON S V IWQA PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signatur Date:
**NOTE** The issuance of this G
has been installed in cc
Disposal Systems," but
iven period o e.
L
n-
CERTIFICA_ TX. COMPLETION
Ttificate ompletion shall indicate the system described on Improvement/Operation Permit
mDk6qe with Article 11 of G. S. Chapter 130A, Section .1900 "Sewage Treatment and
shill i,,N3 WAY be taken as a guarantee that the ystem will function satisfactorily for any
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Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
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Date: B Z►4 Ola
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 990003552
Billed To: Tate Rice Homes, Inc.
Reference Name:
Proposed Facility Residence
P"d /-6�00
Tax PIN/EH #: 5871-61-5955.17 TR
Subdivision Info: Meadows Edge Lot # 17
Location/Address: Brookwood Court -27006
Property Size: see map
ATC Number: 4266
**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 flOL, #People #Bedrooms #Baths 3
Dishwasher: 121"' Garbage Disposal: Q' Washing Machine: ❑'� Basement w/Plumbing: 000' Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size 0--74 AC412=5 Type Water Supply I Design Wastewater Flow (GPD) Site: New Repair ❑
System Specifications: Tank Size ru GAL. Pump Tank GAL. Trench Width Rock Depth !�1 Linear Ft.
Other: �i �1�9-'�1 , Ar:1:3'r �1!
Required Site Mad ifications/Cnnditinnc-- �PI` 10
L-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 # i3 (33Q251-8760 *�** .
Environment THeajth Specialist's Signat�
DCHD 05/99 (Revised)
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supervision from an actual survey made under my supen
No. 3176, recorded in Book as noted, Page , etc.) (other); that the
a subdivision surveyed are clearly indicated as drawn from information
ity that has an Pag` fat the ratio of precision as calculated
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ENONIv"EPJJAL HEALTH
l'SCOUP1TY
N I:Oli SITE [VALUATION/IAII'I(UV[AI[NT i'G111111• & ll•I•C
Davie County Health Department
Ei1yironi»enta/Hes/t/i Section
1.0. Dox 848/210 Hospital Street
Dlocksville, PTC 27028
(33G)751-8760
* * *I2'1PORTANT* * * THIS APPLICATION CANNOT DL PROCESSED UIILLSS ALL THL REQUIRL•'D
IIIFOF1ATIOII IS PROVIDED. Refer to the INFORMATION 13ULLETIN for ilistLuctiorls.
IF FOODSERVICE: It Seats Estimated Water Usage (gallons par day) _ __
B. Typo of water supply: M County/City ❑ Well ❑ Conuuunity
9. Do you anticipate additions or CXI)allsiolls of the facility this system is ill(ended to ser%,C'l 11 yes M No
If yes, what ()'Ile?
'**lAIPORTANT*** CLIEN'rS,1lUST conll'LLTG'rllE IU:'QUIRL•-D PROMRTY INFORMATION RLQ111;STI?I)
3ELO1V. Eithcr n PLAT or SITE PLAN MUSTBESUBMI'l-TrD by the dietll lrilh'1'111S �1I'I'LIC�\'PION.
Pruperty Dilncll5iu115:
'1':ll Office PIN: II
See attached map WRITE DIRLCI•IOtNS (I`rom I\lucksl-ills) to I'It111'lil('I'1':
5871615955 East on Highway 153, turn right onto
1'rol)crly Address: Road Nallle Beauchamp Road
City/Zip Advance, 27006
If in a SubdiY15i011 provide inl'urmalion, as follows:
Name: Proposed Jade Associates
Scctioll: Bloch: Lot: 17
Gun Club Road and proceed to the end of
the road, turn left -onto Beauchamp Road
and the site is located approximately tOo
ni1es down Beaucharp Road on the right and
left side of the road. 3/8/04
Datc home corners flagged:
This is to certify that the information provided is correct to the best ol• illy luloll•ledge. I uaderstand that :illy l)erulil(s)
issued hereafter arc subject to suspcnsioll or I'MCatioll, if (Ile site plans or intunded use cluulge, ur if (lie iufurula(ion
Submitted ill this upplicatiou is f llsilied ur ch:mged. I, also, aulerstaul that I am respuusiblc fur till charges hicturrl/ frurn
Ibis 1111plicatiull. I, hereby, gil•c conscut to the Authorized I1cpre5clllallyc oI tile Davie Cuuuly lle:llttl De`mrhl nl
to enter upon above described pruperly located in Davic County )old uwmd by Jade Associ ates 1 I , tLC
to cunduct ail testiq procedures as necessary to de(crllline (Ile site suitabilil)'.
3/15/04
DA'11 SIGNATURE I -t4'__
T111S AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the fullowhig: Existing and prupuscd
property lines aid dimensions, structures, setbacks, and septic locations).
SAC Revisit Charge
llatc(s):
Client Notificatiuu Date:
ElIS:
sigil given Arrnnnt Nn
Jade Associates II, LLC
Alan Jones
1,
flame to be oillcd
_ CouCact Pcr::un
Post Office Box 4062
nailing Address
vane 11huue
__ __••_•
Ilinston-Salm NC 27115-4062
(336) 759-9688
City/:,tate/'LIP '
1)uJi11U:1.3 1'llul,e
2.
llama on Permit/ATC if Different than Above
Hailing Address
City/SCaLe/Zip
J.
Application For: EX Site Evaluation
❑ Improvement Permit/ATC L1 11oL11
9.
SyrLcm to Service: ® House ❑ I•Iol�ile Home
❑ Du:31I cC ,-s ❑ InduLtry
❑ OLlter -- _-
S.
Type system requested: (gi Conventional ❑ conventional modified ❑
innovaLiva
G.
If Residence: If People 4 11
13CCIroolli5 4
If Bathroullw 2.5
nDiol1waaher r_1Garbage Disposal K Plashing Machina
111JaIICltic 1L/flu Plumbing
7.
If Dunincas/Industry /Other: verify type
It People
11 Uilll:s
1l Commodes 0 Showers
11 Urinalu
II WaLur Cooleru
IF FOODSERVICE: It Seats Estimated Water Usage (gallons par day) _ __
B. Typo of water supply: M County/City ❑ Well ❑ Conuuunity
9. Do you anticipate additions or CXI)allsiolls of the facility this system is ill(ended to ser%,C'l 11 yes M No
If yes, what ()'Ile?
'**lAIPORTANT*** CLIEN'rS,1lUST conll'LLTG'rllE IU:'QUIRL•-D PROMRTY INFORMATION RLQ111;STI?I)
3ELO1V. Eithcr n PLAT or SITE PLAN MUSTBESUBMI'l-TrD by the dietll lrilh'1'111S �1I'I'LIC�\'PION.
Pruperty Dilncll5iu115:
'1':ll Office PIN: II
See attached map WRITE DIRLCI•IOtNS (I`rom I\lucksl-ills) to I'It111'lil('I'1':
5871615955 East on Highway 153, turn right onto
1'rol)crly Address: Road Nallle Beauchamp Road
City/Zip Advance, 27006
If in a SubdiY15i011 provide inl'urmalion, as follows:
Name: Proposed Jade Associates
Scctioll: Bloch: Lot: 17
Gun Club Road and proceed to the end of
the road, turn left -onto Beauchamp Road
and the site is located approximately tOo
ni1es down Beaucharp Road on the right and
left side of the road. 3/8/04
Datc home corners flagged:
This is to certify that the information provided is correct to the best ol• illy luloll•ledge. I uaderstand that :illy l)erulil(s)
issued hereafter arc subject to suspcnsioll or I'MCatioll, if (Ile site plans or intunded use cluulge, ur if (lie iufurula(ion
Submitted ill this upplicatiou is f llsilied ur ch:mged. I, also, aulerstaul that I am respuusiblc fur till charges hicturrl/ frurn
Ibis 1111plicatiull. I, hereby, gil•c conscut to the Authorized I1cpre5clllallyc oI tile Davie Cuuuly lle:llttl De`mrhl nl
to enter upon above described pruperly located in Davic County )old uwmd by Jade Associ ates 1 I , tLC
to cunduct ail testiq procedures as necessary to de(crllline (Ile site suitabilil)'.
3/15/04
DA'11 SIGNATURE I -t4'__
T111S AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the fullowhig: Existing and prupuscd
property lines aid dimensions, structures, setbacks, and septic locations).
SAC Revisit Charge
llatc(s):
Client Notificatiuu Date:
ElIS:
sigil given Arrnnnt Nn
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
• Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003105 Tax PIN/EH #: 5871-61-5955.17
Billed To: Jade Associates II, LLC Subdivision Info: Pro Jade Assoc. Lot # 17
Reference Name: Location/Address: Beauchamp Rd -27006
Proposed Facility: Residence Property Size: see map Date Evaluated:�1 D f%
Water Supply:
Evaluation By:
On -Site Well Community /
Auger Boring Pit ✓
Public
Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
n-10
Texture group
C_
Consistence;
S
Structure
Mineralogy1
HORIZON II DEPTH
t Q ^ 3
2'
Texture group
S' CL +CL+_Salp
Consistence
f SS _
-'E '
Structure
Mineralogy
HORIZON III DEPTH
1113LA -SCS
Texture group
L.
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
o.. '"• .�
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS: --01- C<' avCle—
EVALUATION BY:
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)
Account #: 990003552 Tax PIN/EH #: 5871-61-5955.17 TR
Billed To: Tate Rice Homes, Inc. Subdivision Info: Meadows Edge Lot # 17
Reference Name: Location/Address: Brookwood Court -27006
Proposed Facility: Residence Property Size: see map Date Evaluated: