189 Meadows Edge Drive Lot 10DAVIE COUNTY HEALTH DEPARTMENT
' Environmental Health Section
P. O. Bog 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990001597 Tax PIN/EH #: 5871-61-5955.10 MB
Billed To: Marquis Building Subdivision Info: Meadows Edge Lot # 10
Reference Name: Location/Address: Meadows Edge Dr. -27006
Proposed Facility Residence Property Size: see map
ATC Number: 4047
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 Sewa Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWAT TR TIO IS V R A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signa re: Date: 4,q ia.N
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
given period of time.
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Com\
�qd>✓ j�T�.. -7-31 . `, ,
Septic System Installed By: —S� W
Environmental Health Specialist's Signature: Date: 11 61—
DCHD 05/99 (Revised)
Account #:
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
IMPROVEMENT/OPERATION PERMIT
990001597 Tax PIN/EH #: 5871-61-5955.10 MB
Marquis Building Subdivision Info: Meadows Edge Lot # 10
Location/Address: Meadows Edge Dr. -27006
Residence Property Size: see map
ATC Number: 4047
**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 CONS TRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type 0DOSC #People #Bedrooms '4 #Baths 2' -5—
Dishwasher:
Dishwasher: Garbage Disposal: ❑ Washing Machine: IF Basement w/Plumbing: ❑ Basement/No Plumbing: If
Commercial Specification: Facility Type #People #People/Shift #Seats IndustriallW13Waste:
Lot Size �'t'-lCs Type Water Supply Design Wastewater Flow (GPD) —� n Site: New u Repair ❑
rr
System Specifications: Tank Size ICCOGAL. Pump Tank GAL. Trench Width 360 Rock Depth (Z- Linear Ft. 14(id
Other: 5 jt>yrtd� ZNt�-S
Required Site Modifications/Conditions: It jTgLL Cly Cer 1000-, r 'v IS 6cc aAiw-" 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.****
Pd
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r 150, i
Environmental Health Specialist's Signature: _
DCHD 05/99 (Revised)
10 05 03: 44p
r ,
Gordon Whitney 336 940-6947 p.4
APPUCATION FOR SFFE EYALUATION/IMPROW13KNT PERNFT & ATC
Davie County Health Department
Environmental Health Section
P.O. Box 849/210 Hospital Street
Mockavillo, NC 27028
(336)751-8760
•*tIMPORTANT'**• THIS APPLICATION CANNOT BE FROCESSLD UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed AAla )r1�7j y�.'1t_(i %Jt ..t --IVC contact Person (-fin .Jt_iN4f
Mailing Address P.�t.' fJi7� 0 nome Phone agAa -1A x''
{A
city/state/ZIP o,!A )La tuC_ 2QCO d Business Phone 7A 15 - 31S,',
2. Name On Permit/ATC if Different than Abovo
Mailing Address City/State/zip
3. Application For: ❑ Site Evaluation i,Improvement.Permit/ATC. 11. Both
4. System to Service: ❑ House n Mobile Home ❑ Business //fl Industry 0 Other
S. If Residence: I People A Bedrooms / Bathrooms Z 11Z -
6
1Z
6
1+ Dishwasher.. 0 aarbage.tlisposal. (,Washing. machin LI Basement Plumbing
If Business/Industry/Others specify type / People
commodes $ Showers /.Urinals
)Q Basement(No Plumbjng
I Sinks
I water Coolers
IF FOODSERVICE: 0 Seats Estimated Hater Usage (gallons per day)
7.. Type. of.water.supply: County/City Q well 11 Communitlr
y. no you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Ll No
If yes, what type?
***IMPORTANT*** CLAM" MUSTCOMP/_ETETHE REQUIRED PROPERTY INFORMATION REQUFsTED
BF.1.OW.. Eitbera PLAT os SITE PLAN MLISTSESUEMnTED by the client with THIS APPI.ICATIOK
Property Dimensions: %G 1,
38Vv 9 24n * 2131 WRITE DIRECTIO.NNrS+(rf�rom Mocksville) to PROPERTY:
Tax Office PIN: a f J"
71 '(L /ter S S 1 e 1�. 1 :M10 }�G 7��
I—,
PropertyAddrew.. Road Name A�}7a-. F� i —yi
. i-1 CywCtAriino
Cityaip &k'w;CF OL, L7106
If in a Subdivision provide information, as follows:
Name:—lvt��•11+.., ; �!17l F� l
lection: �_ Block: Lot: i O Date Property Flagged: � O
')'his is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(�-)
issued bercafter 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_ 1, also, understand that l am reWausible for all charges incurred from
this application. 1, 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 by
to conduct a1F testingnxedares as necessary to determine the site stripe ity. i
6&
DATE ! SIGNATURE U
THIS AREA MAYBE USED TOR DRAWING YOUR SITE PLAN (Include all of the following: Exis .og and proposed
property lines and dimensions,- structures, setbacks, and septic leestieas).
Revised DCHD (07/99) r
,4.VJ C�
EJl J I s/ e- N
Site Revisit Charge
Date(s):
Client Notification Date:
EFTS:
Account No. 7
Invoice No.��
r'�' /�-- a s
.,flpr 10 05. 03:44p
Gordon Whitnetl
ME
KVA�
336 940-6947
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D E 11 ICATION 1:011 SITE- L•VALUATION/lAlf'IiOVL-AIEN-I-1'Llill117• & A'I'C
P1�AR 1 5 2004 Davie County Health Department
` EnYironmenta/Hes/t/i Secti011
P.O. Dox 848/210 Hospital Street
1---- Mocksville, NC 27020
ENVIRDA IE C00TY�LTN
(33G)751 -07G0
* * *1NPORT.tINT * * * THIS APPLICATION CANNOT DE PROCL:SSL'D UIILLSS ALL HE REQUIlmD
I11FOR1dATION IS PROVIDED. Refor to L•ho INFORUATION DULLETIN fol ills L-I:uctiOrlil.
-
1. !fame t0 be billed ConLacL Ncrnon
Mailing Address Post Office Box 4062 liouie !'hone
City/.;talc/'LIP
Winston-Salem' 11UJ1llU:1:1 L'lwric NC 27115-4062 (336) 759-9688
2. flame on Permit/ATC if Different than Above
Nailing Address City/StaLc/Zip
3. Application For: M Site Evaluation ❑ Improvement Permit/ATC ❑ Doth
4. Syctem to Service: ® House ❑ lfobile Home ❑ DuaincL•s
ti
5. Type system requested: M Conventional ❑ conventional modified
G. If Residence: It People 4 11 Bedrooms 4
❑ Industry ❑ OtIlcl:
❑ innovativu
l]Diahwasher ElGarbage Disposal nklashing Machine ❑Da cuicnC/11wiJ�ing
7. If Duainena/Induatry /OL•her: verify type It People
0 Commodes 0 Showers 11 Urinala
II bathroolm; 2.5
®IlacemenL/no Plwubin�
It WaLur Coolers
IF FOODSERVICE: I1 Seats Estimated Water Usage (gallons per day)
8. Type of water supply: In County/Ci L -y ❑ Well ❑ Couuuuni ty�V
9. Do you anticipate additions or C\pall5iD11S of the facility this sysmil is ill (Cil dell to selwe? ❑ Yes rr1 NU
If yes, what type?
***!nr!'olcrfiYr*** CLIEN'rSillUSTCOd1PLLTG'rllL REQUIRED PROPLI(TY 1NFORNIr1'I'lON IttsQUI.STI•:U
BELOW. I;itllcr n PLAT orSIT,E PLAN d1USTBESURIV17YED by the clicut irilh'1'I11S A('PI,IG\'PION.
1'rulwl-ty Dimensions: See attached map
Tax Office PIN: 1l 5871615955
Property Address: Road Name
City/Zip
Beauchamp Road
Advance, 27006
If ill a Subdivisiall provide infurnlatioil, as fulloivs:
Name: Proposed Jade Associates
Scctiou: Bloc!:: Lot: . 10
WRITE' DIRLC IONS (Tran! 5lucLSville) lu PROPI;I(•I.V:
East on Highway 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 too
rules down Beauchamp Road on the right and
left side of the road. 3/8/04
Date llonic corners flagged:
This is to certify that the iuforivatioilprovided is correct to the best of my lulowledge. I understand that :uly perulil(s)
issued llcrcal'tcr arc subject to Suspension or revocation, if (lie site plans ur intended Ilse change, ur if the iufurnlatiun
subuti(ted in this applicatioll is falsified or changed. I, also, 1111derstall ! illat 1 (till regmIlsible jul'rill chtl es ill eurn Wfiw ill
this application. I, hereby, give consent to the Authorized Representative of the Da%,ie Cutin (y ln
Ilc:dtll Dc rtu Ln
to enter upon above described pruperly lucaled in Davie County and UwIled by Jade Assoc! ates
to CuuduC( all tcstiug procedures as ncccssary to dc(crulillC the site suitability.
3/15/04 �)
DATE - - SIGNATURE t iG,, � � ✓
T'Ii1S AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the fulluiyhig: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
llatc(S):
Client Notification Date:
EI•IS.
Sign given _ ,,.,. .,... IV
APPLICANT INFORMATION
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
PROPERTY INFORMATION
Account #: 990003105 Tax PIN/EH #: 5871-61-5955.10
Billed To: Jade Associates II, LLC Subdivision Info: Prop. Jade Assoc. Lot # 10
Reference Name: Location/Address: Beauchamp Rd -27006
Proposed Facility: Residence Property Size: see map Date Evaluated: _ 2-S Cy
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit V/ Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
C
Slope %
D
HORIZON I DEPTH
C7 2G
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
2ri ^5
7►21
Texture groupS"
L'1
Consistence
S
SS.
Structure
SG14
Mineralogy
;
HORIZON III DEPTH
Texture group5
i L
Consistence
ECSS
Structure
, IL
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
.�
SITE CLASSIFICATION: r
LONG-TERM ACCEPTANCE RATE: r
REMARKS:
EVALUATION BY:
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)