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128 Brookmead Court Lot 19DAME COUNTY HEALTH DEPARTMENT �. Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 /,& Account #: 990002436 Tax PIN/EH #: 5871-61-5955.19 DB Billed To: Darren Burke Constr. Reference Name: Proposed Facility Residence ATC Number: 3998 Subdivision Info: Meadows Edge Lot # 19 Location/Address: Beauchamp Rd -27006, Property Size: see map 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 Treatme t and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONST R VAL FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: 2 �J O VU Y 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, SeTfibr,1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guararlRe that the system function satisfactorily for any given period of time. • X 2� �ba�-eJT•wlc Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) 'F(Lo-TV �R--iA.r,5to6 ." W•aLL Date: 9 / 2,!VD6— DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002436 Billed To: Darren Burke Constr. Reference Name: Proposed Facility Residence Tax PIN/EH #: 5871-61-5955.19 DB Subdivision Info: Meadows Edge Lot # 19 Location/Address: Beauchamp Rd -27006 Property Size: see map ATC Number: 3998 **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 4"t_` #People L4 #Bedrooms L4 #Baths 2 -'- Dishwasher: 171�' Garbage Disposal: ❑ Washing Machine: ET- Basement w/Plumbing: Ey�- Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 1.455" Type Water Supply c-.WAPY Design Wastewater Flow (GPD) 4-10 Site: New 25� Repair ❑ System Specifications: Tank Size ICCO GAL. Pump Tank GAL. Trench Width 3b Rock Depth 0/0, Linear Ft. qot:� Other: t71S�'21TtOr�!CS ��tJ lam, l:-�TL 1�Q-,� 1►� Required Site Modifications/Conditions: j "QLL.- C'_5 �� w= a� �t ��S %� V13S 10 apF g4p'o. L�1 a e - IMPROVEMENT/ PERATION ERMIT LAYOUT - APPROVED EFFLUENT FILT R. RISER(S) IF 6 " BELOW FINISHED GRAD . ****NOTIC : Contact a representative of the Davie County Health Department for final inspection of this system between 8: 0 a.m. to 9:30 a.m. r 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone# is (336)751-8760.**** /c'vo�t�p� DCHD 05/99 (Revised) .SL?srot, ~roar P%eeTTS -r14 &�r>U: Pewa- -Tt�' Date: ' Co 22� Og / CH w a o� 74.52 = U 1d - i Ar� U -)N c . •� Avau �? �yo-os co luau, a � . 4f ',6 091 S 1 F CD Co cj , 07 !110 N N „V C� —_�— co u L � � u Co d. 8' 0 O ..34' 23r W �� N 09' 24 44 W 184•g� 297.10' a� 1 F Co cj , 07 „V C� S 1 F Co cj 1 F Feb 11 05 10:22a Lot 20 Lot 19 M DVE0510i p.2 S 81.3926, w 1 221.w Brookmead Court NI _I t 1r ` \ \O�� to ua Artr Ea9ameM. . 01 m i / Lot 18 Proposed Layout For Darren Burke Construction Company, Inc. Lot 19 Meadows Edge PB S Pg 144 1 inch = 50 feet 7 Property Addr : Road N2—_Z 13 t7L CltcrwttA Cltymp__ lit'Vel 171,7 (L� If in a Subdivision provide Infornsaaon, as follows: ,.tti7/i� Name: aA," Section: Block: Lot:_ Date borne corners (tacgcd: This Is to certify that the information provided is correct to t)te best of my knowledge. 1 tuiderstaud that any permil(s) issued hereafter arc subject to suspeuan, or revocation, If Vie site plans or intended use chauge, or if the infonnatiou submiued In this application is fatsirwil or changed. I, also, anJm=twid that lam respuoaibk far ull chases inedrresiJrna, This opplication. f, hereby, sive consent to the Authorized Rcprc5cutative of the Davie CountVItcallh Oeparluucut, to oder upon above described property located in Davie County and owned by IJC..�ri'✓� _�iiJ� Ci �.:, �"•r � to conduct all (sting procedures as umcssary to determine the site suilabi 't t DATE t ^t fJ " !� SIGNATURE _ THIS AREA MAY BE USED FOR DRAWING YOUR SIZE PLAN (faciude aU or abet rollosriog: Existing and proposed property lines anddimensloas, struclarts, setbacks, andsepticlocations). Site Revisit Charge Di tc(s): Client Notifteation Date: Sign givenAeeount No. Revised DCHD (OSM3 Invoice No. i Jun la 03 11:14a davie county envhealth. 336 751 8766 p.2 API'UCA7lON FOIL SITE EVALUATION/IMPROVFRIENT 1113031-t y ATO ' Davie County Health Department r ; Enviivnmen6/Nea/1l1 Section P -O. Box 848/210 Hospital Street �• Hocksville, NC 27028 v (336)751-8760 IMPORTANT"",THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL TILE REQUIRED. • INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instruetiono. 1. Name to M �../ Gilled Gz r!- CCA - j f`tontaet PRr000 Mailioq Addreaa i1 "U 1 lWnc Phone 7(1 l! ai/-r _ •�r/� V �.1t ^•f Gley/Jtatc/LZP rw ,Ot (J�(I i-- C, :270�uc. evstaeea Phone 2. X— on P*mltfA:C if Different CLaa Above Malting Add.... city/state/z1D �� __ .•• - - ��/1� A'� (• 1. Application For: Q Site _.va.luntion ❑ Improvement Permit/ATC oth ry t. Jrataa to service: House ❑ Mobile Fane ❑ Business ❑ Industry ❑ Other S. Type ayetem requeeted,Xtbaveatioaal ❑ eoovencional modified ❑ Inn ... tivo S. it Reeideneet a people _ P Bedrooms d Bathrooms lahweber ❑a.rbega Diepoaal �*ahinq Maebioe *seeeot/P1u,enlmq ❑0aeca,ent/ao Pluad)lnq T. (((((( it eveinedefindustry /Other: verity type 0 People d Slnka �•.� a Coenodea a :hover. P urioalm a Nater eoolora XF POODSERVICZ: a Seat.. 8atL—ted Mater usage (oration. Dar doyl IN a. Type of v.ter-Vplya)Goua Cy/City ❑ well ❑ Community,.,/ 9. Do you, anticipate additiooc expansions of the facility this systetn Ls In(endcd to wrve! ❑ Yes `\P Nu u n � J� If yrs, wbal type' •`•IAfp T.tN7"•.CLIEN':SAfUSTC'OAIP TCTItEICCQtffNCUI'1t01'ER•1'YINP'01iMATIONItV'QlllSl'lill BELOW. fFt tr o PIAT or SI YE PLAN DE SUBMITTED by the client with T'NLS API'LICATION. 77 Properly Dimctssious: • % x X;?alf WRITE DIRRCCI'IONS (twin nloc"villt){/lu�.VROPL'ICIA': Tax Office 1'I - it`� l " 5 -L51 Property Addr : Road N2—_Z 13 t7L CltcrwttA Cltymp__ lit'Vel 171,7 (L� If in a Subdivision provide Infornsaaon, as follows: ,.tti7/i� Name: aA," Section: Block: Lot:_ Date borne corners (tacgcd: This Is to certify that the information provided is correct to t)te best of my knowledge. 1 tuiderstaud that any permil(s) issued hereafter arc subject to suspeuan, or revocation, If Vie site plans or intended use chauge, or if the infonnatiou submiued In this application is fatsirwil or changed. I, also, anJm=twid that lam respuoaibk far ull chases inedrresiJrna, This opplication. f, hereby, sive consent to the Authorized Rcprc5cutative of the Davie CountVItcallh Oeparluucut, to oder upon above described property located in Davie County and owned by IJC..�ri'✓� _�iiJ� Ci �.:, �"•r � to conduct all (sting procedures as umcssary to determine the site suilabi 't t DATE t ^t fJ " !� SIGNATURE _ THIS AREA MAY BE USED FOR DRAWING YOUR SIZE PLAN (faciude aU or abet rollosriog: Existing and proposed property lines anddimensloas, struclarts, setbacks, andsepticlocations). Site Revisit Charge Di tc(s): Client Notifteation Date: Sign givenAeeount No. Revised DCHD (OSM3 Invoice No. i R C�CC��1C• 1' ATION 1:01( SITE 1MLUATION/IAII'1tovaiEN-C t'L•1ti11I7 & ATC MAR 5 2004 Davie County Health Department &y1roxue17ta/11e,7&i Section ENVIRONMENTAL HEALTH P•0. Dox 848/210 IIospiLal StrccL DAVIECOUNTY riocksviile, RC 21020 (336)751-0760 ***XNPORTANT*** THIS APPLICATION CANNOT DE PROCESSED UNLESS ALL TIM REQUIRED• ..' I I1IFORMATION IS PROVIDED. Refer to the INFOIZ14ATION DULLETIN for illsLrucLiollD. Jade Associates II, LLC A1a11 Jones 1. name CO be Dillcd Con Lac L' 1'crsoct Mailing Address Post Office Box 4062 nowc 1111onc City/:,talc/'LIP llinston-Salem, NC 27115-4062 (336) 759-9688 nusine�s 1'1)unc 2. )lamo on Pcrmit/ATC if Different than Above Mailing Address City/Stato/Zip 3. Application For: M Site Evaluation ❑ Improvement Permit/ATC ❑ Ifuth 4. System to Service: ER House ❑ I•Iobile Home ❑ Dusinc"o ❑ 1'lldusL3:y ❑ Other _ _— y S. Type system requested: lel Conventional ❑ conventional modified ❑ innovaLive G. If Residence: 1t People 4 II Bedrooms 4 It bathroo1w; 2.5 C:1DIDhwasher Larbage Disposal nWashing Machino M13aceuwnL/1'lwnbing ❑Dace1ttenL/110 Plumbing 7. If Dusinens/Industry /OLhor: verify type I! i'cottic It inl;n I Cotnmodon 11 Showers 11 Urinals It WaLor Cooleru IF FOODSERVICE: It Seats Estimated water Usage (gallons por day) 8. Typo of water supply: In County/City ❑ well ❑ ConuuunitylhS 9. Do you anticipate additions or C\I).Ulsiolls of (lie facility this s)'stclll is itltetldc(I to ser%'e'l ❑ Yes m IN 1f)'cs, 11'llat type'' '**IM PORP'/INT*** CL11iNTS MUST couj LL•TG'r11L !(liQumL'U va0l'UtTY INFORMATION RE'QI11?S'I'I?U 3EL015'. Eilhcr a PLAT or SITE PLAN HUSTUESUUblITTED by the client 1ri111 '1'1115 Al'I'I,IG1'1'ION. 1'ruperly Diulcn5iuns: Tax Office PIN: I{ See attached map 5871615955 Property Address: Road Nanlc City/Zip Beauchamp Road Advance, 27006 DIRL;C IONS (from Il•lucl(sville) lu 1'1(0I'I•:I('I'1': East on Highway 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 information, as follows: and the site is located approximately two Name: Proposed Jade. Associates ni1es down Beaucharap'Road on the right and left side of the road. Section: Block: Lot: 19 Datc home corners !lagged: 3/8/04 This is to certify that the information provided is correct to the best of my knowledge. 1 understand (lilt .1113' perulit(s) issued hereafter arc subject to suspcusion or rcvoca(io11, if (11C si(c 11.1115 u" intended use change, ur if (lie infur111116on subuli((ed in this upplicatioll is falsilicd or changed. I, also, andersturrrl flint I am re5punsiblo fur all Charges ilrc•lu•ri'd. i•urn Ilds application. I, herebp, give consent to (he Au(llorized 11epreseuL•1(ive of the 1)Ivie Cu1u11)' 11c:1It11 I)e ):u•tM cal1 to clue" upon about: described pruperly located in Davie County and owned by Jade Associates � I, LL I; to cunduct III testing procedures 15 IICCC55.11'y to dCNI-Iniac (lie site suilabilily. 3/15/04 DA'I'S SIGNATURE wt � ✓ THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (I11cludc all of llle fullolviug: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). . Sign given Site Revisit Charge Client Notification Date: I:IIS: A(,rnimf Nn —3 / t7 . DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003105 Tax PIN/EH #: 5871-61-5955.19 Billed To: Jade Associates II, LLC Subdivision Info: Pro Jade Assoc. Lot # 19 Reference Name: Location/Address: Beauchamp Rd -27006 Proposed Facility: Residence Property Size: see map Date Evaluated: _312 -tom of Water Supply: On -Site Well Community / Public I, Evaluation By: Auger Boring Pit t/ Cut FACTORS 1 2 3 4 5 6 7 Landscape position M,L Slope % C, -7C ryp c'7 HORIZON I DEPTH 0-1X - I • `3 Texture group C -L_ rL, G Consistence ( i Structure Q Mineralogy" HORIZON II DEPTH 2Z 7Lr 1"1 f7.5c) • SCS Texture group1L C Consistence i — , Structure k Mineralogy1 HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS O RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION _g LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: h"> EVALUATION BY: _,�U' r — 6m0a A -(J LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: e 144i1jkt) C/�� / �i (7 1 a Q 1 I 6- _T' 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) \ r�9- auc Phone: (336) - 753 - 6780 Davie County Health Department Environmental Health Section Data: N// 15 Rwetved by: P.O. Box 848 210 Hospital Street Courier #: 09-40-06 Mocksville, NC 27028 Fax: (336) - 753-1680 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement emodeling Reconnection Name: Phone Number 3 36' 7 �o '7-` ,.F Home Mailing Address: (Work) t/ o-vLy, / Email Address: Detailed Directions To Site: 1.�� ^ C Gd�'o 12✓ d '^ P 61 0 k bcYL�� fp &gAzv -s 676e, Property Address: Please Fill In The Following Information About The EXISTING Facility: C_1K Name System Installed Under: Type Of Facility: Date System Installed (Month/Date/Year): rg 00` Number Of Bedrooms: Number Of People:_5� Is The Facility Currently Vacant? Yes Any Known Problems? Yes 6) 6 D If Yes, For How Long? If Yes, Explain: Please Fill In The Following Informa ion About The NEW Fac' ity: /^ Type ty: Sh d`� �Ye �Dr Number of People % T e Of Fac umber f Bedrooms: Pool Size: Size: Other: Requested By: DateRequested: For Environmental Health Office Use Only rove Disapproved !�( Comments: / /moi C4,1:& � ✓� . 1I �5�� e 1�'�✓` C Environmental Health Date: %/ -- 6' F_ *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash Qheck Money Order # O) O)S bK f) Amount:$ I UV k) () Date; Paid By: Received By: Account #: 7 Invoice #: I- �-d e C969-OV6-9SC 4-j uOsJel9d doo:Zo 9 6 SZ loo Lt �-d e C969-OV6-9SC 4-j uOsJel9d doo:Zo 9 6 SZ loo