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: