152 Meadows Edge Drive Lot 21Account #:
Billed To:
Reference Name:
Proposed Facility
DAME COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
990003620 Tax PIN/EH #: 5871-61-5955.21 GB
Graystone Builders, Inc. Subdivision Info: Meadows Edge Lot # 21
Location/Address: Beauchamp Rd -27028
Residence Property Size: 134 x 229
ATC Number: 4088
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 Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTE W C IS V D FOR A PERIOD OFFIYEARS.
Environmental Health Specialist's Signatur : Date:
CERTIFICATE OF COMPLETION
NOTE* * The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
2 1- has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and
=i�e.�� that thesystem will function satisfactorily for any
givel�I§eriod
QVIU 4
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
G��yti=
'041
- DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990003620 Tax PIN/EH #: 5871-61-5955.21 GB
Billed To: Graystone Builders, Inc. Subdivision Info: Meadows Edge Lot # 21
Reference Name: Location/Address: Beauchamp Rd -27028
Proposed Facility Residence Property Size: 134 x 229
/I. -C3
ATC Number: 4088
**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 I 1 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 G #People #Bedrooms #Baths 7
Dishwasher: bl"" Garbage Disposal: 173
Commercial Specification: Facility Type
Washing Machine: Basement w/Plumbing: Er"" Basement/No Plumbing: ❑
#People #People/Shift #Seats Industrial Waste: ❑
Lot Size14 'RJE. Type Water Supply &VWTy Design Wastewater Flow (GPD)fl Site: New Repair ❑
System Specifications: Tank Size WD GAL. Pump Tank GAL. Trench Width Rock Depth I2 Linear Ft. 7LL-/(
Other: I0�li�laJ�5
Required Site Modifications/Conditions: �rQLL— (�►v GCS r / /� fi��%i ��
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 # is (336)751-8760.****
�g
o Qp
W
t
CJs; 4`A#
Environmental Health Specialist's Signature:
VdP 2
DCHD 05/99 (Revised)
CO rn 15' Side MBL (typical)
[V S 00' 1524" W
CO 0 r�
N - : a 229.50'
1
0
15' Side MBL (typical)
o
H-
I
O?
�
G)
o
CO
'
�
W
W I
�01
CDD
.-.
^
O
> Qi0 25' Street Side MBL (typical)
CD _120.05'_ = 229.50'
,OA 10' Utility Easement
• U) -4'. 1. --b N ^0_10-1574" E 349.55'
"a L J Brookmead Court (Public 50' R/W), 27' BC --BC
CD
(� _ 2 Q S0' ,d S 00' 15'24" W 278.84'
'S �v 10 Utilit Easement _
� '� 55.80' 223.03'><O
yo
TA
00
rn I -a
Cn
CATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
MAY 1 Q 20Q� Davie County Health Department
Environmental Health Section
P.O. Box 848/210 Hospital Street
ENVIRONMENTAL HEALTH Mocksville, NC 27028
DAVIECOUM (336) 751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
J
I. Name to be BilledL�I�,t[s'7'dr--I� �LL7t.l� S X-� ontact Person � (�2A, -7gE:-AJ3R!'1
Mailing Addres^s P, CO -Ac* I S -i e. Home Phone
City/state/ZIP L(�'Y» I'1/W �..1 S A) e'7 --701Z Business Pho33jL 54s,- (ac 4 2--
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: ❑ Site Evaluation nprovement Permit/ATC ❑ Both
4. System to Service: ,House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
S. Type system requested: ❑ Conventional ❑ conventional modified ❑ innovative
6. If Residence: # People # Bedrooms Z-)_ # Bathrooms
Aishwasher ❑Darbage Disposal dashing Machine Arnasemont/Plumbing ❑Basemont/No Plumbing
7. If Business/Industry /other: verify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: It Seats Estimated Water Usage (gallons per day)
e. Type of water suppiy.;,>ff County/City ❑ Well ❑ Community
9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes A�tNo
If ycs, what type?
***L11P0RT11N7'*** CLIENTS MUST COAIPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Eithcr a PLAT or SITE PLAN bfUST BES11BA11T1'ED by the client witli THIS APPLICATION.
Properly Dimensions: !� �"/ 1VRITE DIRECTIONS (from Mocksville to PROPER' '1':
�Officc if
PP p rty Address: Road Name E0-0'-t'c� �= �-/ � i %�o
City/Zip
If in a Subdivision provide information, as follows:
Name: ") '0—� L`✓ -S E
T
Section: Block: Lot:
JY',% L eS b N )
Date home corners flagged: J5 0 /0J
This is to certify that the information provided is correct to the best of my knowledge. I understand that any perntit(s)
issued hereafter are 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 au: responsible for all charges incurred front
this application. I, Hereby, give consent to the Authorized Representative of the Davie County IIeal(h Department
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine the site suitability.
DATE . - S SIGNATURE
TIIIS AREA MAYBE USED FOR DRAWING YOUR SITE PLAN (Inclu all of
property lines and dimensions, structures, setbacks, and septic locative/
ocati
UP -
✓v
Sign given
Revised DCHD (05103
and proposed
Site Revisit Charge
Dale(s):
Client Notification Date:
EHS:
Account No. ai " b
Invoice No. 7 '�
i
Meadows JEdge oflve
GlvySVonc �uilde�5, h7c,
/,o/ Z/, I'leadow5 �aqe
Davie Gounfy, NG
40
Apfll 12.1200-15
,L:1
—,' �'^ � (1 1 n E
r "lvJ' H14 V
p,RAR 1 5 2004 1 1 ATION 1:011 SITE EVALUATION/lAll'110VUIL•NT I'LRAUT & )VTC
1� Davie County Health Department
EnYirOiri»enta/Hc�,7&11 SectiOil
ENVIRONMENTALHEALTH P.O. Dox 440/210 Hospital SLrccL
DAVIEcoun blocksville, NC 27020
(33G)751-8760
* � *IDIPORTANT* ** TRIS APPLICATION CANNOT Dl; PROCESSED WILLSS ALL TILL REQUIRL D I
IIIFORMATIOII IS PROVIDED. Refer to the INFORMATION BULLETIN for inotrucui0nu.
Jade Associates II, LLC Alan Jones
1. None to be Dillcd Con lac l' 1'crsun
mailing Address Post Office 60x'4062 110111c Phone
City/State/'LIP
llinston-Salem' DUJine9a Phuue NC 27115-4062 (336) 759-9688
2. llama on Permit/ATC if Different than Above
Nailing Address Ci Ly/SLaLe/'Lip
1. Application For: Site Evaluation 4 ❑ 2:mprovement PC1:wiL/ATC ❑ Both
4. SyaLem to Service. ® House ❑ 1•I0bile Home ❑ 1JuSil1C!':J ❑ IuduL.Lry ❑ Other -- --
• ti
S. Type system requested: M Conventional ❑ conventional modified ❑ innovaLive
6. If Residence: 11 People 4 1) Bedroom,- 4 II BaLhi:ooiwc 2.5
LDiahwasher tGarbage Disposal KlWashing llachino ML3ascmenL/l'lumbiuc) ❑Da::elaenL/110 Plumbing
7. If Dusiness/Industry /OLher: verify type 11 People If inla
9 Commodes 31 Showers II Urinala 11 lgaLer Cooluru
IF FOODSERVICE: It SeaL-D Estimated Water Usage Gallons per (lay)
8. Typo of water supply: 16 County/City ❑ well ❑ ConununitytwS
2. Do you anticipate additions or e\p:UISiolls Of the facility this systelll is 1ll(clided lu ser%'e'1 ❑ Yes oCv Nn
If )'cs, 11 -hat type?
**IA1P01tT11/YT*** CLICN'FSMUST C0n11'LLT1:TIIL 1tL'QUIRED PROPERTY INVOIWATION RLQUl;STED
;CLoll'. E3dlcr a PLAT or SITE PLAN MUST BESUUd117YED by the clicnl lrilll'1'1115 Al'PLICA'I'ION.
Pruperty Dimensions
Tax orrice 11IN:
See attached map
11 5871615955
Properly Address: Road Name Beauchamp Road
City/Zip Advance, 27006
WRITE' UIRLCTIU1NS (from Alucl(sville) h) I'KOl'I:It'1'1':
East on Highway 158, turn right onto
Glen
Club
Road
and proceed
to the end of
the
road,
turn
left -onto
Beauchamp Road
If in a Subdivision provide infurnlation, as fullutvs: and the site is located approximately trio
Na1)lc: Proposed Jade Associates hii 1 es down Beauchamp 'Road on the right and
21
left side of the road .3/8/04
Section: Block: Lot: Date !ionic corners flagged.-
This
lagged:
This is to certify that tic information provided is correct to the best of my 1u1o1vicdge. I understand 01.11 :1113, perilik(s)
issued hereafter arc subject to suspension or revocation, if Ute site plans or intended use chauge, or if elle iufurnnl(ion
submitted in this application is falsilied ur changed. 1, also, tulders7ruul flint run relrultsible jur• rill Charges irrcurn'd fir•rr/if
this application. I, hereby, give conscut to (lie Authorized llcprescnta(ivc of the Davie C011111)' lleallll I)chlHil 11
l
to enter upon above described pruperly localed ill Davie County and uivllcd by Jade Associ ate 1 C
to culduct all testing procedures as Necessary (o (IC(el'lllillC the site suitabiht)'. --��
DATE 3/15/04 SIGNATUIIL � �r
THIS ARLA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of lllc fullul)'ing: Existing and prupused
property lines and dinlellsialls, structures, setbacks, and septic locations).
Site Revisit Charge
llatc(s):
Client Notification Date:
ERS:
Sigel given
Avrnnnf Nr,
• t DAVIE COUNTY HEALTH DEPARTMENT
` Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003105 Tax PIN/EH #: 5871-61-5955.21
Billed To: Jade Associates II, LLC Subdivision Info: Pro Jade Assoc. Lot # 21
Reference Name: Location/Address: Beauchamp Rd -27006
Proposed Facility: Residence Property Size: see map Date Evaluated: S121OI_t� _
Water Supply:
Evaluation By:
On -Site Well
Auger Boring
Community
Pit W"
Public
Cut
FACTORS
1
3 4 5 6 7
Landscape position
L-
Slo e %
j24
HORIZON I DEPTH
O �q
Texture groupQ
Consistence
S
Structure
G6L
C
C
Mineralogy
HORIZON II DEPTH
i 1r 33
." X
- 2
Texture group
C
Consistence
—5 P;
Structure
5
Mineralogy
t
HORIZON III DEPTH
2l - '
Texture group
S;C
--:;:C_ASQ0h
Consistence
S
`
Structure
A'
MineralogySte:
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
, . S
O•
SITE CLASSIFICATION: �J S
LONG-TERM ACCEPTANCE RATE:
REMARKS:
EVALUATION BY: 'N�_—_ btmx'o A"`
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)
1