Loading...
131 Meadows Edge Drive Lot 4Account #: Billed To: Reference Name: Proposed Facility DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 a 990003476 Fowler -Jones Construction Residence ATC Number: 3977 0/1- 1-31-()�;- Tax PIN/EH #: 5871-61-5955.04FJ Subdivision Info: Meadows Edge Lot # 04 Location/Address: Meadows Edge Dr. -27006 Property Size: 143'x 210' 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 Treatmqnt and Disposal Systems). THIS AUTHORIZATION FOR WASTEWAT VA D F A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: J 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 .......-. -.,.-:-A ..F 4:... e Septic System Installed By: ��..••�� Environmental Health Specialist's Signature : �I✓ l �" Date: 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 #: 990003476 Billed To: Fowler -Jones Construction Reference Name: Proposed Facility Residence Tax PIN/EH #: 5871-61-5955.04FJ Subdivision Info: Meadows Edge Lot # 04 Location/Address: Meadows Edge Dr. -27006 Property Size: 143'x 210 ' ATC Number: 3977 **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 v6L)s'= #People #Bedrooms #Baths Ll Dishwasher: CY Garbage Disposal: O� Washing Machine: ❑"'_ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type El(n1 #People #People/Shift #Seats Industrial Waste: Lot Size 0 -LA &Cus Type Water Supply OA01,3� Design Wastewater Flow (GPD) 4ZD Site: New 171"" Repair ❑ System Specifications: Tank Size IDODGAL. Pump Tank GAL. Trench Width -:5. Rock Depth 12- Linear Ft. qcc> Other: Required Site Modifications/Conditions: Et- Id oFf- RO-OP L-1 J s IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FINISH ****N ontact a representative of theavis a qty Health'Department for final inspection of this system between 8:30 a.m. to 9:30 a.m. oi 1:00 p.m. to 1:30 p.m. on the day of installation. jelephone#is(336)75I-8760.**** Y:�� w` v3 $S -------------- Mia. �P�vE Environmental Health Specialist's Signature: ate: DCHD 05/99 (Revised) APPLICATION FOR SITE EVALUATION/IAIPROVEAIENT PERMIT & ATC Davie County Health Department Environmental Heath Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS -PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed I " (� (> I' - �) ( 0e1 ' C, e O I'1 5 f r_ Contact Person 0v CeII Mailing Address (i r� D}c%{ 1 (�, Home. Phone City/State/ZIP i ni \o1-) SO,.�j/i') IL(L %i(1=j Business Phone __��(y - `7rJQ •q� �j'{� 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: ❑ Site Evaluation City/State/Zip YImprovement Permit/ATC ❑ Both 4. system to Service: ,House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other _ 5. Type system requested: P"Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People # Bedrooms # Bathrooms 7. DishwaaharGarbage Disposal Washing Machine If Business/Industry /Other: verify type # Commodes # Showers IF FOODSERVICE: ## Seats ❑Basement/Plumbing ❑Basement/No Plumbing # People # Sinks # Urinals # Water Coolers Estimated Water Usage (gallons per day) 8. Typo of water supply: County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this systein is intended to serve? ❑ Yes ❑ No If yes, what type? ***I/l1P0RTANT*** CLIENTS MUST COAfPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN AfUST III: SUBMITTED by the client with TIIS APPLICATION. Property Dimensions: J4 o c X �y b Tax Office PIN: #E�7a WRITE DIRECTIONS (from Mocksville) to PROPERTY: Property Address: Road Name Mon rf o (, Erb cK I r R : Q. 4 r? 14 kck City/Zip _Arl \ yblu R( X'70 v [, I_ p C F a a C U o n n pl e_ If in a Subdivision provide information, as follows: Name: 019 n Section: Block: Lot:_ Date home corners flagged: /- - 7-OJ— This is to certify tliat the information provided is correct to the best of my luiowledge. I understand that any permit(s) issued hereafter arc subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred fron: this application. I, hereby, give consent to the Authorized Representative of the Davie County IIcalth Department to enter upon above described property located in Davie County and owned by l-"c.,A, iF,_Jnr7F 5 Crnf,t rkci� r -)c' rTrir to conduct all testing procedures as necessary to determine the site suitability. DATE I - _, 'T c I;- SIGNATURE (?""A14 TIIIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Liclude all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Sign given Revised DCIID (05/03 Site Revisit Charge Datc(s): Client Notification Date: EIIS: Account No. �P Invoice No. ��� p EC E" MAR 15 2U�r, . , 1 PLICATION 1:011 SITE EVALUATION/lAl! IiOVL•AIEN-I' 1 LIIAil7' a life Davie County Health Department ENVIRONMENTAL HEALTH fnviroili»enta/Hes/t// Section DA'J{ECOi'idTl' P.O. Box 848/210 Hospital StrccL' Mocksville, 11C 27020 (336)751-8760 * * *.rkjPORTANT * * * THIS APPLICATION CANNOT BE PROCESSED U11LESS ALL THE REQUIRED ILIFORIIATION IS PROVIDED. Refor to tho INFORMATION 13ULLETIN for inoLlruclionu. Jade Associates II, LLC Alan Jones 1. ttamc to be Billed Contac L 1'ersoli _—_ -: Nailing Addrens Post Office Box 4062 Nonle Phone City/:,tate/'LIP llinston-Salem' lluuinu:rs Phuno NC 27115-4062 (336) 759-9688 2. Namo on Permit/ATC if Different than Above Nailing Address City/SLatc/Zip 3. Application For: If Site Evaluation g ❑ IlnprovelnenL PerlaiL/ATC L1 nuLh 9. System to Service: ® House ❑ Mobile Home ❑ iiuz;incL, s ❑ Industry ❑ Othar_- ti S. Type system requested: M Conventional ❑ conventional modified ❑ innovaLive G. If Residence: 11 People 4 11 Bedrooms 4 II 1SaLhro0l11u 2.5 LJ Diahwasher In Garbage Disposal nklashing Nachino ❑llasemen L/l'lwiding ®Da.'emcn L/llo Plumbing 7. If Dusiness/Induotry /OLhcr: verity type 11 People II :;inhr' 11 Commodes 11 Showers 11 Urinalu it WaLer Coolcru IF FOODSERVICE: I1 Scats Estimated Water U-,agc (0allona pur day) 8. Type of water supply: In County/City ❑ Well ❑ ConuuuiiiLy�,vt 9. Do you anticipate additions or Csp.111SiUlls of (lie f;icility this S}'stclll is itlicildcd to serve? L-3Yeson No 1f yes, 11 -hat type? ***1A11'0RT1llYT*** CLIEN'rSalUSTCOnI!'LLTG'ritL 1WQUIRED PROPLI(TY IlNVORn1,1'IION REQIIESTE, D UELOIV. I:idier n PLAT orS1TE PLAN 1UUSTBESUl111f1T7YiD by the ciicol 11-ill,'1'1(IS AI'i'I,iCA'I'ION. Vruperty DilnGisiuns: See attached map 11'!tl'f1S U1REC IOiNS (from Alucltsvillc) In I'1t01'I;It'I'1': T.Iz Office 1'IN: /I 5871615955 East on Highway 158, turn right onto I'rolicrty Address: Road Name Beauchamp Road City/Zip Advance, 27006 If in a SubdiYi5ioll provide illl'ur111at(011, :u fullOWS: Nalllc: Proposed Jade Associates SCC(ioll: Bloch: Lot: 4 Gun Club Road and proceed to the end of the road, turn left -onto Beauchamp Road and the site is located approximately two ni1es down Beauchamp Road on the right and left side of the road. 3/8/04 Datc ho13,c curios lDt;t;cd: This is to certify that the information provided is correct to (lie best of my kll0WledgC. I Ulldw-stand that any permil(s) issued llcrcaf(cr arc subject to suspcusion or revocation, if the site plans ur illtcudcd use CII;utgc, ur if (lie iufurlu:llion subini(tcd in this application iS L•tlsilied ur changed. I, Also, fill derstullit that 1(1111 rrspuasible jut all c'hal-yes ill c•Nrred.li'uIll this upplicatiuu. I, licreby, give consent to (lie Authorized Representalivc of (lie D;ivic Cuunly I1c:11(Il De 1:11•lu cni to cuter upon above described pruperly lue.ited in Davie County atid ulvucd by Jade Associ ates I , tLtl to conduct all tesliug procedurcS as recess;u'y to dCteruline (Ile site suitability. 3/15/04 ���� DATL SIGNATURI: THIS AREA MAYBE USED FOR DRAWING YOUR SITE PLAN (Include all of clic fulluiying; Existing mid prupused prol)erty lines and dilnensioiis, structures, setbacks, and septic locations). Silc Revisit Cllargl D:1lC(s): Client Nutifirttiou Dale: E. Sign givcu ,N .......... , nr,. 3 / 0 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003105 Tax PIN/EH #: 5871-61-5955.04 Billed To: Jade Associates II, LLC Subdivision Info: Prop. Jade Assoc. Lot # 04 Reference Name: Location/Address: Beauchamp Rd -27006 Proposed Facility: Reesidence Property Size: see map Date Evaluated: �?�jp� Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH Texture group of .tom CIL Consistence frs 5P kMr Structure Mineralogy HORIZON II DEPTH 2 r "7- Texture group Consistence , Structure 513le Mineralogy1 HORIZON III DEPTH Texture groupCC C� Consistence Structure mift 53 Mineralogy; HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE r SITE CLASSIFICATION: P� LONG-TERM ACCEPTANCE RATE: 0 - 0 REMARKS: LEGEND Landscape Position EVALUATION BY: 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) Davie - County Health Department Environmental Health Section mr ••j r �� � P.O. Box 848 -210 Hospital Street. ;k 4 Courier # : 09-40-06 =A� Mocksville, NC 27028 r' Phone: (336) - 753 - 6780 Fax: (336) - 753-1680 ON-SITE WASTEWATER CEICATION, FOR DWELLING (Check One) ReplacementRemodeling Reconnection Name: �� ��/f�/(J%�/L% Phone Number (Home) Mailing Address: (Work) Site: I J � _74d , A6�Y liMdrC, f—d . hl/N , ked Detailed Directions To Property Address: Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: rotfilt"-11 VU/UC=S Type Of Facility: f,�QllJL� Date System Installed (Month/Date/Year): 11d7,7/64 Number Of Bedrooms:_�_' _Number Of People: Is The Facility Currently Vacant? Yes (2�pl If Yes, For How Long? Any Known Problems? Yes If Yes, Explain: Please Fill In The Following InnJf,�,ormation About The NEW Facility: Type Of Facility: �%CU L16 JJ JG'(W�%Ai" Number Of Bedrooms:-- Number of People, Pool Size: Garage Size: Other: Requested By:�lCEN�9f (d�6 ON V0 Date Requested: & - I -Z -1b (S ignature) Ap roved Disapproved Comments: /'AQ i vL yG Environmental Health Specialist For Environmental Health Office Use Only k Date: /f) — 11 " *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 Check Money Order # Amount:$ Date: Paid By: Received By: Account #: Invoice #: