183 Meadows Edge Drive Lot 9;j DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section vt�
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760�Q
Account #: 990003476 Tax PIN/EH #: 58711-61-5955.09 FJ
Billed To: Fowler -Jones Construction Subdivision Info: Meadows Edge Lot # 9
Reference Name: Location/Address: Meadows Edge Dr. -27006
Proposed Facility Residence Property Size: see map
ATC Number: 4183
As steted in 15A NCAC 18A.1969(5)
accepted Systems may also be used
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 WASTEW TIZ7—Date:
A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signatur DS
CERTIFICA
**NOTE** The issuance of this Certificate of Completion 1.
N has been installed in compliance with Article of
Disposal Systems," but shall in NO WAY er}�
given period of time.
lam' /3e t!.lT 70
# 1 - $S'
:F 7 - Wq - J(., cAO-4
PF 1476 1� -
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
a
ON
( stem described on Improvement/Operation Permit
130A, Section .1900 "Sewage Treatment and
: that the system will function satisfactorily for any
Date:
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 Tax PIN/EH #: 5871-61-5955.09 FJ
Billed To: Fowler -Jones Construction Subdivision Info: Meadows Edge Lot # 9
Reference Name: Location/Address: Meadows Edge Dr. -27006
Proposed Facility Residence Property Size: see map
ATC Number: 4183
**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 fIoosc #People #Bedrooms L— #Baths
Dishwasher: Garbage Disposal: ❑ Washing Machine: 2"'� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply Design Wastewater Flow (GPD) Site: New Repair ❑
System Specifications: Tank Size 10TO GAL. Pump Tank GAL. Trench Width Rock Depth 12j1 Linear Fts'-
1969(5)
Other: V/ � ��i1�1 ac stated in 15A NCAC als18Ao
be used
accented Systems may also b used
Required Site Modifications/Conditions:
ZS
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EF 11LEN-rFILTER. RISER(S) IF 6 " BELOW
FINISHED GRADE. ****NOTICE: Contact a representatry he Davie County Health Department or final inspection of this
system between 8:30 a.m. to 9:30 a.m. or for l — to 1106—.m. p.m. on the day of installation. Telephone # is 36)751-8760.****
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131
Environmental Health Specialist's Signature
DCHD 05/99 (Revised)
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GRAPHIC SCALE
0 20 40 80 180 N❑TEj
\SURVEYOR HAS MADE NO INVESTIGATION OR INDEPENDENT SEARCH FOR
EASEMENTS OF RECORD, ENCUMBRANCES, RESTRICTIVE COVENANTS,
WNERSHIP, TITLE EVIDENCE, OR ANY OTHER FACTS THAT AN ACCURATE
IN FEET 4,D CURRENT TITLE SEARCH MAY DISCLOSE, THIS SURVEY IS PERFORMED
I inch = 40 ft. WITHOUT THE BENEFIT OF A TITLE SEARCH.
NOTICE-.
FOWLER JONES CONSTRUCTION HAS VERIFIED TO ALLIED LAND
SURVEYING COMPANY, P.A. THE EXTERIOR HOUSE DIMENSIONS FOR THIS
EXISTING HOUSE/STRUCTURE. HOUSE POINTS AND POSITION SHOWN ON
THIS MAP REPRESENT THE POINTS TO BE PLACED ON THE PROPERTY.
THE OWNER/CONTRACTOR HAS REVIEWED ALL HOUSE/STRUCTURE
DIMENSIONS, SETBACKS FROM PROPERTY LINES, AND COMPLIANCE WITH
RESTRICTIVE COVENANTS AND/OR LOCAL GOVERNMENTAL
REQUIREMENTS ON THIS DRAWING AND BY THEIR SIGNATURE
AUTHORIZES ALLIED LAND SURVEYING COMPANY, P.A. TO PLACE THE
POINTS AS ACCURATELY AS IS REASONABLE (TYPICALLY 0.02'±).
OWNER/CONTRACTOR TO VERIFY THE PLACEMENT OF POINTS SET IN
FIELD PRI❑R TO AUTHORIZATION OF FOOTINGS/BRICK MASONS/
CONSTRUCTION TO PROCEED. BY SIGNING THIS STATEMENT OWNER/
CONTRACTOR FULLY ACCEPTS THEIR RESPONSIBILITY TO VERIFY
POINTS IN FIELD. THE HOUSE POINTS DENOTED BY SOLID FILLED
CIRCLES ARE THE ONLY POINTS TO BE LOCATED IN THE FIELD. ALL
OTHER BUILDING CORNER LOCATIONS ARE TO BE THE RESPONSIBILITY
OF THE UNDERSIGNED CONTRACTOR/DEVELOPER.
ACKNOWLEDGMENT,
OWNER/CONTRACTOR
_ DATEi
FIELD REVISION, __________________________ DATE,
OWNER/CONTRACT❑R/ALLIED STAFF
PRELIMINARY LAYOUT
LOT 9
'Meadows Edge'
Phase I
Plat f ori Alan Jones
ALS PROJECT NOi PRELIM
NOTE:
THIS PLAT DOES NOT REPRESENT A CURRENT FIELD SURVEY. ALL LOT
DIMENSIONS HAVE BEEN TAKEN FROM THE PLAT OF MEADOWS EDGE,
PHASE 1, LOCATED IN PLAT BOOK 8 PAGE 143. NO TITLE RESEARCH
HAS BEEN PERFORMED OR REQUESTED FOR THE BENEFIT OF THIS PLAT.
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..Jan 2G 05 10:10a davie county envhealth 336 751 8786 p.3
, r A
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERM, C
Davie County Health Department AUG 2 3 2o05
Environmental Health Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028 0iWR0iVi;SQ7TAINE4LTH
(336) 751-8760 DAVIECOUW
I ***IMPORTANT*** THIS APPI:ICATION CANNOT DE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Dilled �Fb)yjev rnn S4 rtrrii0 Contact Person 4 �1�,?v�jl7►YS
Mailing Address PO T-�DX 11+04 -Pi Nome Phone
city/state/ZIP '_-�Business Phone
Z. Name on Permit/ATC if Different than Above
Mailing Addresa C
ity/State/Zip
3. Application For: ❑ Site Evaluation q0. Improvement Permit/ATC ❑ Doth
4. System to service: gHouse ❑ Mobile Homo ❑ Business ❑ Industry ❑ Other
S. Type system roquested:�q Conventional ❑ conventional modified ❑ innovative
6. If Residence: # People # Bedrooms 14 # Bathrooms `3
7.
❑Dishwashor ❑Garbage Dispc,3al ❑Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing
If Business/Industry /Ot:hart verify type.
d Commodea # :.bowers
IF FOODSERVICE: # Seats
e. Type of water supply: ❑ COun ty/City
# People # Sinks
# Urinals # Water Coolers
Estimated Water Usage (gallans par day)
❑ well
❑ Community
9. Do you anticipate additions oz expansions of the facility this system is intended to serve? ❑ Yes
If yes, what type?
❑ No
***IMPORTANT*** CLIENT: AfUSTMUPLETLTIIE RLQUIRE•D PROPERTY INFOItMAT10N REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBAIITTE•D by the client ivitit THIS APPLICATION.
PropertyDimcusions: g(P-13' )(a3o,t+•r x 165'1" X
309.1431
Tax Office PIN: {F 5Ss`l I l r 5 g S
Property Address: Road Nano Meodoa '` ',
City/tip Adva.r,re N r .
If in a Subdivision provide information, as follows:
Name: McDiiouoa5 45AQ,P
Section: Block: _ Lot: q --
WRITE DnmcrIONS (rrom Moclavillc) to PROPERTY:
R;hd.CI `jCreY`'l
1 _P�-� - KeauL-i-torn�� ?<k f_n 0-
Date honic corners nagged: ho 1, oIran>ti„ hoon
/'r141 r ka'iJ
This is to certify that the information p.-uvided is correct to the best of my lutowledge. I understand that any pernift(s)
issued lureaftcr 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 t/tat l ant responsible fur all charges lucurred jruut
this application. I, Itereby, give consent to ilia Authorized Representative of the Davie County licilth Department
to enter upon above described property located in Devic County and owned by I~ovvtPr44%Ya4rL# ri ; r,rj C
to conduct all testing procedures as neerssary to determ(tle the site suitability.
DATE g ,'t :3 - D.5' SIGNATURE
TIIIS AREA MAY BE USED FOR DRbtWING YOUR SITE PLAN (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Sigh given
1Vv
Revised DCIiD (05/03
Site Revisit Charge
Datc(s)•
Client Notification Date:
EFIS-
Account No. 3 V7
Invoice No.
CRQ'4i'4R'F
-"F D
GRAPHIC SCALE
20 a so
( IN FEED )
I Inch - 40 IL
NOTE,
SURVEYOR HAS MADE NO INVESTIGATION OR INDEPENDENT SEARCH FOR
EASEMENTS OF RECORD, ENCUMBRANCES, RESTRICTIVE COVENANTS,
WNERSHIP, TITLE EVIDENCE, OR ANY OTHER FACTS THAT AN ACCURATE
D
CURRENT TITLE SEARCH MAY DISCLOSE, THIS SURVEY IS PERFORMED
W HOUT THE BENEFIT OF A TITLE SEARCH.
N❑TICE:
FOWLER JONES CONSTRUCTION HAS VERIFIED TO ALLIED LAND
SURVEYING COMPANY, PA. THE EXTERIOR HOUSE DIMENSIONS FOR THIS
EXISTING HOUSE/STRUCTURE. HOUSE POINTS AND POSITION SHOWW ON'
THIS MAP REPRESENT THE POINTS TO BE PLACED ON THE PROPERTY.
THE OWNER/CONTRACTOR HAS REVIEWED ALL HOUSE/STRUCTURE -
DIMENSIONS, SETBACKS FROM PROPERTY LINES, AND COMPLIANCE .WITH -
RESTRICTIVE COVENANTS AND/OR LOCAL GOVERNMENTAL
REQUIREMENTS ON THIS DRAWING AND BY THEIR SIGNATURE
AUTHORIZES ALLIED LAND SURVEYING COMPANY, P.A. TO PLACE THE
POINTS AS ACCURATELY AS IS REASONABLE (TYPICALLY O.OZ't),
OWNER/CONTRACTOR TO VERIFY THE PLACEMENT OF POINTS SET IN
FIELD PRIOR TO AUTHORIZATION OF FOOTINGS/BRICK MASONS/
CONSTRUCTION TO PROCEED. BY SIGNING THIS STATEMENT OWNER/
CONTRACTOR FULLY ACCEPTS THEIR RESPONSIBILITY TO VERIFY
POINTS IN FIELD. THE HOUSE POINTS DENOTED BY SOLID FILLED
CIRCLES ARE THE ONLY POINTS TO BE LOCATED IN THE FIELD. ALL
OTHER BUILDING CORNER LOCATIONS ARE TO BE THE RESPONSIBILITY
OF THE UNDERSIGNED CONTRACTOR/DEVELOPER.
ACKNOWLEDGMENT-
OWNER/CONTRACTOR
DATE]
FIELD REVISION- __________________________ DATE,
OWNER/CONTRACTOR/ALLIED STAFF
PRELIMINARY LAYOUT
LOT 9
'Meadows Edge'
Phase 1
Plat fors Alan Jones
ALS PROJECT NO, PRELIM
NOTE:
THIS PLAT DOES NOT REPRESENT A CURRENT FIELD SURVEY. ALL LOT
DIMENSIONS HAVE BEEN TAKEN FROM THE PLAT OF MEADOWS EDGE,
PHASE 1, LOCATED IN PLAT BOOK 8 PAGE 143. NO TITLE RESEARCH
HAS BEEN PERFORMED OR REQUESTED FOR THE BENEFIT OF THIS PLAT.
Allied Land Surveying Co., P.A.
4720 KESTER MILL ROAD Surveyed by-
WINSTON-SALEM, NORTH CAROLINA 27103 Dram By JCM
Phone: (336)765-2377 Fax: (336)760-8886 Project No. PRE
e-mail: Info@Allicd-EngSurv.com Date: B/B/2005
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1,1AR 1 5 20M 1"LICATION 1:011 SITE EVALUt1TION/lAIP1IUVL'All:NT l'L•1G111T & ATC
f Davie County Health Department
EnviToai»enta/He,7&1 Section
ENVIRONh1ENIALHEWH P.O.Dox 848/210 Hospital Street
DA�'IECOUiITY ttocksville, ITC 27020
(33G)751-0760
***IMPORTANT*** THIS APPLICATION CANNOT DE PROCESSED UNLLSS ALL THE RLQUIRM) � I
I11FORMATION IS PROVIDED. Refer to the INFORtdATION DULLETIN for ilirt ucliorl_l.
1. llama to be Dillcd
Jade Associates II, LLC CoAlar?. Jones
nl'acl 1'crson _
Nailing Addre:j:; Post Office Box 4062 noluc 1'hunc
C1 ty/:+CaCC/LIP
Winston-Salem,
UU;I ill 1`:1:1 1�)lU1lC NC 27115-4062 (336) 759-9688
1. llama on Permit/ATC if Different than Above
Nailing Address Ci Ly/StaLc/Zip
3. Application For: lX3 Site Evaluation ❑ Improvement Penni!'/ATC ❑ DuLh
g
9. 5ystem to Service: E3 House ❑ Idob•ile Home ❑ UuoincLs ❑ Industry ❑ Other -- --
ti
S. Type system requeoted: ill Conventional ❑ conventional modified ❑ iunovuLivu
6. If Residence. 11 People 4 U 13edLoomc 4 II Datilrovm:. 2.5
bDiahwasher InGarbagc Disposal nklashing Ffachino ❑DaSC1nCnL/Plumbing ®LacaulcnL/Ilo Plumbing
7. I£ Duaineos/Industry /Other: verify type 0 People
9 Commodea 11 Showcrs II Urinalu
I) :;ills
11 WaLor Coolcru
IF FOODSERVICE: It ScaLD Estimated Plater USa1c (gallonD pur day)
e. Type of water supply: In County/City ❑ Well ❑ ConuuunitylM
9. Do you anticipate additions or C\pa11S1Ulls of IIID facility (Ills sys(clll is illll:lldcd lu Nerve? ❑ yes OCV No
If yes, what type?
***IA11'0R;G1tYT*** CLIEN'rSd1USTC01111'LL''TG'r1iL RLQU11(L•'D I'R0I'L•'I('l'Y INFORMATION 'QUESTED
BELOW. l;i(ilcra PLAT orSITE PLAN t)1USTBESU111111T ArD I)3, (lie clieol 11ith'I'IIIS Al'PLIC,�'l'101t.
1'rul)crt), Dinlcnsiulls:
See attached (nap
Tax office PIN: 11 5871615955
Property Address: Road Natlie Beauchamp Road
City/Zip Advance, 27006
If ill a Subdivision provide infurmatiotl, as fullolvs:
Nalllc; Proposed Jade Associates
Section: Block: Lot: 9
WRITE' UIIWCTIUNS (fruul 1lluclm-illc) lu
East on Ilighway 158, turn right onto
Gun Club Road and proceed to the end of
the road, turn left -onto Beauchamp Road
and the site is located approximately two
Iii les down Beaucharap 'Road on the right and
left side of the road. 3/8/04
Date Ilonle curlers !lagged:
This is to certify that Ilse infornlatioa provided is correct to the best ol'luy lulolvlcdge. I understand (lett any perluii(s)
issued hereafter arc subject to suspension or revocation, if (lie site plans ur intended use ciculge, or if the !nl'urulatiun
sublui((ed in this application is f:dsilied ur changed. 1, also, untlerstantl that! lin reapunsible jut' ull charges ittcurrrtl /ruin
this application. I, hereby, give conscut to (llc Authorized ltcprescntativc of [lie Davic CuullO' Ilcalth De ):11.111cu
to enter upon above described pruperty located iii Davie County and ulrncd by Jade Assoc i ates
to cunduct all testing proccdul'cs as ncccssa!'y to determine (lie site suitabilil)'.
3/15/04
llA'!'E SIGNATURE
TIlIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Iucludc all of the fullowhig: Exisling and prupused
property lines and dimensions, structures, setbacl(s, and septic locations).
Site Itevisit Clcu'ge
D a(c(s):
Client Nolificaliuu Dale:
EIIS:
Sign given
A1. ....f TTf.. D/0S
4 • '
V.,
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION
Account #: 990003105
Billed To: Jade Associates II, LLC
Reference Name:
Proposed Facility: Residence Property Size:
Water Supply:
Evaluation By
On -Site Well
Auger Boring
PROPERTY INFORMATION
Tax PIN/EH #: 5871-61-5955.09
Subdivision Info: Pro Jade Assoc. Lot # 09
Location/Address: Beauchamp Rd -27006
see map Date Evaluated: 2S
Community
Pit ✓/
Public
Cut
FACTORS
3 4 5 6 7
Landscape position
—
Slope %
C
2V
HORIZON I DEPTH
0-11
Texture group
G
Consistence
F i
Structure
Mineralogy
HORIZON II DEPTH
Texture group
•S; C.L. C•}
L C•f
Consistence
Fr I`S
IJ
Structure
0S
k
Mineralogy
HORIZON III DEPTH
3`) P
7— JD
Texture groups:
L `&
Si L uO
Consistence
f�
� o
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: S
LONG-TERM ACCEPTANCE RATE: 1
REMARKS: `�' o OF GO) h as _— C+Q1a0
LEGEND
Landscaae Position
EVALUATION BY: tawLb4�
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)