Loading...
145 Meadows Edge Drive Lot 5DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003476 Billed To: Fowler -Jones Construction Reference Name: Proposed Facility Residence ATC Number: 3978 Tax PIN/EH #: 5871-61-5955.05 Subdivision Info: Meadows Edge Lot # 05 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 Trpatment and Disposal Systems). THIS AUTHORIZATION FOR WASTE N I _ OR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signatur Date: i 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 I 1 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. Re,-- `61?AU—Cj � s `1 Lb. -I 0 Septic System Installed By: �,•td.,r•,.�. Environmental Health Specialist's Signa tur Date: DCHD 05/99 (Revised) 4 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 990003476 Tax PIN/EH M 5871-61-5955.05 Billed To: Fowler -Jones Construction Subdivision Info: Meadows Edge Lot # 05 Reference Name: Location/Address: Meadows Edge Dr. -27006 Proposed Facility Residence Property Size: 143'x 210' ATC Number: 3978 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a 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 i a #People #Bedrooms L4 #Baths L4 Dishwasher: Er Garbage Disposal: Q"_ Washing Machine: 13 Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 0•1 �c Type Water Supply �V`STY Design Wastewater Flow (GPD) 490 Site: New Repair ❑ System Specifications: Tank Size 1000 GAL. Pump Tank GAL. Trench Width;!V Rock Depth 12 1 Linear Ft. 14(4(:� Other: . �JtSrfL►3t�r1o•� ' Required Site Modifications/Conditions: �`� �:.t' "t ep- }- M2E) �c ��� �' �' 5 IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW 'FIN f9ffE _GkADE. ****NOTIC • Contact a representative of the Davie County HealthDepartmentfor 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. ephone # is (336)751-8760.**** 37' ( I :� 9 iElZ Q H� ult Environmental Health Specialist's Si ature: DCHD 05/99 (Revised) Ro, qor (00' .- �• I M►j•� 101 i 0 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department EnvironmentaiHealth 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 k(' r l )()ja S C Ci )'1 � fr Contact Person IQr7 ,1 QI Mailing Address (�C� r� O}� %�{� Com. Phone City/State/ZIP W 6 n i t -b y1 - Q�NIJ) i(-t� �71(Cj Business Phone j,3 & - 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip _ 3. Application For: ❑ Site Evaluation Improvement Permit/ATC ❑ Both 4. System to Service:fi;�House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: WConventional ❑ conventional modified ❑ innovative 6. If Residence: # People # Bedrooms # Bathrooms '- Dishwasher Garbage Disposal Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks # Commodes # Showers IF FOODSERVICE: # Seats # Urinals # Water Coolers Estimated Water Usage (gallons per day) 8. Type of water supply: County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes, what type? ***IMPORTANT' CLIENTS.MUST COd1PLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN dfUST BE- SUBMITTED by the client with THIS APPLICATION. Property Dimensions: 1.14 ?� . h u r X d IU ' WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # rJR-.05, Igg, -E Property Address: Road Namefelon d r.,, ))rI�1�4 14 � rno f�� kcK City/Zip Ll\yu-�ry niC a ?�y (, Le139a PAZ Inoalp Rd - If in a Subdivision provide information, as follows: Name: Mo 11 &r ua-�-� P-AQ'0, Section: Block: Lot: a� Date home corners flagged: /- ?7-PJ— This 7-°J This is to certify that the information provided is correct to the best of my knowledge. 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 iacu red from this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned byc,w, iE,._J o��Fs C'rmstruci� c:� .rTnc , to conduct all testing procedures as necessary to determine the site suitability. DATE I --'7- c'j SIGNATURE .i,%.r/r e3-U�_d"1L1 AJ7 THIS 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). S° -7 Sign given N Revised DCIiD (05/03 Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. Invoice No. b �' p EC E WE MAR 1 5 2004 1I ENVIRONUIENTAL HEALTH DAVIE COUNTY 'LICATION 1:011 SITE L•Va1LWIT10N/IA11'1tUVLAILN•1' I'Llti1ll1" & NX Davie County Health Department EnYiroi�menta/Hes/t/� Section P.O. Dox 848/210 hospital Strcct hlocksvi.11e, NC 27028 (336)751-8760 * * *XNPORTANT* * * THIS APPLICATION CANNOT DL PROCESSED U1ILESS ALL Tim REQUIRED IIIFORMATION IS PROVIDED. Refer to L•ho INFORMATION DULLLTIN for il10L1:uCL•i0rlD. Jade Associates II, LLC Alan Jones 1. Name CO be Gilled Jade ►'crson Hailing Address Post Office Box 4062 llomc 1'Itonc City/State/'LIP Ilinston-Salem, PJC 27115-4062 (336) 759-9688 IIU7111CDD 1'hwto 2. Namo on Permit/ATC if Different than Above Hailing Address J. Application For: M Site Evaluation City/SLaLc/Zip ❑ Ilnprovclncnt Permit/ATC 4. 5yctem to Service: 12 House E3 Mobile Home ❑ Du;;incDD ti 5. Type system requested: M Conventional ❑ conventional modified d4 4 U. If Rest once. Dishwasher It People It 1 oul:00a1:, InGarbagc Disposal nNashing Machine 7. If Duniness/Industry /OLher: verify type ❑ Industry ❑ OLltcr LJ 17vL'11 ❑ innova Llvc II IsaLllro�,u:; 2.5 ❑DascmcnL/Pl=binU II People N Commodes 11 Showers 11 Urinala 111Da:'C111Q11L/tl0 Plumbing U Siuls II WaL'or Coolcru IF FOODSERVICE: It Seats Estimated WatCr Usage (Uallons per day) 8. Type of water supply: In County/City ❑ Well ❑ ConununiLywrS 9. Do you anticipate additions or Cxp:1115i011s Uf [lie facility this sy5(clll is ill(ellded (U sel'1'0 ❑ yes eel No If 3'C5, what ()'I)C' '**IA1J'01?T11)YT*** CLILN'rs))IUSTCo)1/l'LL•'TL•'-'FILE 1U,QU11(L•'U 1'ROI'LUTY INFORMATION ItlSLl11:5'I'I:U 3EL011'. Either a PLAT or SITE PLAN r11USTDESURMIT%LL) b)• (lie clilvll ,rilh'1'1115 r1l'I'1,IC�1'1'IOIY. 1'ruper0. Dinlcnsiu)Is: See attached map Tax Office PIN: # 5871615955 Property Addre55: Road Name Beauchamp Road City/Zip Advance, 27006 If ill a Subdivision provide iufurntalion, is fullutivs: N;Illlc: Proposed Jade Associates Scctiou: Block: Lot: 5 1VJU'l'L UIRLCTIONS (frust (llut isville) lu I'R01'I-.*UT1': East on highway 158, turn right onto Gun ('luh Riad and Droceed to the end of the road, turn left -onto Beauchamp Road and the site is located approximately two miles down Beauchamp'Road on the right and left side of the road. 3/8/04 Date hume corners !lagged: This is to certify that tic information provided is correct to the best of my lulowledge. I understand that ally pei'mil(s) issued hereafter are subject to 51.151)c11sion or revocatioH, if the site plans ur iu(eaded use ch;ulge, ur if (lie infurlua(iuu subuli(ted in this application is falsified ur changed. 1, also, underslruld that 111/11 regwllsible fur all clans es ill cl -n d.%ruul this application. I, hereby, give miseut to (lie Autllo►•ized Represcula6ve of the llavic Cuuul)' I1e:111I1 to culcl' upoll aboYe de5C1'ibcd prulm'l)' lucaled in Davie County and owned by Jade Associates L to cunducl all lestiug procedures as 11ecC55al'y to dCte►'uliue the si(e 51.1it:lbilil)'. 3/15/04 �� DATESIGNATURE� �,, Cif„•--'' THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (II►clude all of the followbig: Existing and prupused property liras and dimensions, structures, setbacl(s, and septic locatiolls). Site Revisit Clcu'ge Client Nutificatiun Date: E. IIS: sign given A """.—I nr,. 3 /0-57 DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003105 Tax PIN/EH #: 5871-61-5955.05 Billed To: Jade Associates II, LLC Subdivision Info: Prop.Jade Assoc. Lot # 05 Reference Name: Location/Address: Beauchamp Rd -27006 Proposed Facility: Residence Property Size: see map Date Evaluated: Water Supply: Evaluation By On -Site Well Community Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position 1-11 Sloe % 2 0 HORIZON I DEPTH Texture group C Consistence sy Ffs9so Structure C,4V- Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence — Structure Mineralogy(� HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE d SITE CLASSIFICATION: -PS LONG-TERM ACCEPTANCE RATE: 15S REMARKS: EVALUATION BY:6`-E rJ 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 Health Department. I -,116116 Environmental Health Section i P.O. Box 848 p , I' 210 Hospital Street- ro, t 1V Courier # : 09-40-06 Mocksville, NC 27028 __ ? Phone: (336) - 753 - 6780 Fac: (336) - 753-1680 ON-SITE WASTEWATER CERTIFICATIOQ FOR DWELLING (Check One) Replacement"""' Remodeling Reconnection Name: 15&,v2- r Phone Number T.5'65' �.D- :5-5.27 (Home) Mailing Address: /-.3V#�,'�I� �$ �a✓1-�c` 1FV0' % 3(Work) Detailed Directions To Site: Property Address: -nb,q,geo `s Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: 1—( ud elt- no us (iNS� Type Of Facility: Date System Installed (Month/Date/Year):'Jz(C�Q� Number Of Bedrooms: T Number Of People: Is The Facility Currently Vacant? Yes1 0 If Yes, For How Long? Any Known Problems? Yes ,jSrA If Yes, Explain: Please Fill In The Following Information About The NEW Facility: /, Type Of Facility: GyU05rd beol--, Number Of Bedrooms: Number of People Pool Size: Requested By: Approved Comments: C / I. Size: Other: C <APt2 1 Xlb Date Requested: For Environmental Health Office Use Only Disapproved Q44,0) di -`L tt )t'(?��l ln)t-i�,ln DrIC�lf� ddiI`rL"iIlli 0 f ( Environmental Health Speci4i'st XAC�j p "In,, cT ; I Dater ZU l D *The signing of this form by the En mental Health Staff is in no vHy intended, nor should be taken as a guarantee vi n (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # Paid By:_ Account #: _Amount:$_ Received By:_ Invoice #: Date: