198 Meadows Edge Drive Lot 14DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 /Fax # (336)753-1680
OPERATION PERMIT
Account #: 990003552 Tax PIN,EH #: E816OA0014
Billed To: Tate Rice Homes, Inc. Subdivision Info: Meadows Edge Lot # 14
Reference Name: LocationiAddress: Meadows Edge Dr. -27006 �G
Proposed Facility: Residential Property Size: 0.69 Ac
ATC Number: 5978
**NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC 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.
System Type fA Qq S.T. ManufacturerShA Tank Date 1' Tank Size 1D
Pump Tank Size IX$D Bedrooms:
System Installed By: - rA VVS6R Installer# Date:
GPS Coordinate:
n
2l/7(
o,
. >z.
u'
Dhar
Fd ,
a
NX4
Environmental Health Specialist Date: )oj-zqjjS
DCHD 11/06 (Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990003552 Tax PIN,EH #: E8160A0014
Billed To: Tate Rice Homes, Inc. Subdiv!si6n lnfoc: Meadows Edge Lot # 14
Reference Name: LocationiAddress: Meadows Edge Dr. -27006'
Proposed Facility: Residential Property Size: 0.69 Ac
ATC Number: 5978
Site Type: ONew ❑Repair ❑Expansion
**NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental.
Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A
Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat
or the intended use change.
Residential Specifications: # Bedrooms 3 # Bathrooms2& # People Basement,10 Basement plumbingN
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size 001- Type of Water Supply: ❑County/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow (GPD) 3(00Tank Size 000 GAL. Pump Tank/600 GAL.
Trench Width_ Max. Trench Depth_2&" Rock Depth Linear Ft.c %b
Site Modifications/Conditions/Other: 2educ�ioY!
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760.
Environmental Health
Date: a5 f 2
llavie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780/Fax(336)753-1680
IMPROVEMENT PERMIT
Account #: 990003552 Tax-PIN/EH #: E816OA0014
Billed To: Tate Rice Homes, Inc. Subdivision Info: , Meadows Edge Lot # 14
Reference Name: LocationlAddress: Meadows Edge Dr. -27006'
Proposed Facility: Residential PtiSpriy Size: 0.69 Ac
ATC Number: 5978
**NOTE* *This Improvement Permit DOES NOT authorize the construction of a wastewater system. An
Authorization To Construct a wastewater system must be obtained from this office prior to the
construction/installation of a wastewater system or the issuance of a building permit(in compliance with
Article 11 of G. S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to
revocation if site plans, plat or the intended use change.
Permit Type: IgNew ❑Repair ❑Expansion Permit Valid for: 50 Years ❑No Expiration
Residential Specifications: # Bedrooms 3 : # Bathrooms # People BasementX Basement plumbing(
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD):364 Type of Water Supply: 18 County/City ❑ Well ❑ Community' Well
Site Modifications/Permit Conditions:
Site Plan
9�
S stem Type LTAR
Initial 057okeduchofn
Repair ' K
Environmental Health SPL list DateW
i.p. 11-06
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Environmental Health
P.O. Bog 848/210 Hospital StreetECEIVE q
Mocksville, NC 27028 �p q�
S
2� 2 (336)753-6780/ Fax (336)753-1680 � "� ;
Application ❑ Site Evaluation/Im t5vement Permit eAuthorization To Construct _ Both
Type of Appli _ s pair to Existing System ❑ Expansion/Modification of Exis ' yste acility
***IMPORTANT*** THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT WFORMATTON
Name 7 ce Contact Person %, AE9
Address O Q Home Phone
City/State/ZIP ' . ,,UC 7_76/1 —Business Phone 3g�j —2-'
Email �oc,Ec �j-iz�,{�ricejt�T ,
Name on Permit/ATC if Different than Above
Address
FKUYhK 1 Y INP UKM.A 11UN
"`Late House/Facrltty Comers
NOTE:, A survey plat or site plan must accompany this application. Included: P -Site Plan ❑Plat(to scale)
(Permit is valid for 60 months with site plan, no expiration with complete plat.) 3 - 2g06
Owner's Name' " A � //&,.cs Phone Number
Owner's Address Q z City/State/Zip GCo r,.z ucp 270[ Z
Property Address City &Jje" Q
Lot Size Tax PRO j�F_91& 04 001c
Subdivision Name(if applicable)_Fame- Section/Lot#_� nn //--
Directions To Site: l✓.l� �/�
If the answer to any of the following questions is,"Yes",supporting documeptation must be attached:
Are there any existing wastewater systems on the site?
%.-�o
Does the site contain jurisdictional wetlands?
_Yes
Yes v<O
Are there any easements or right-of-ways on the site?
_Yes L, -go
Is the site subject to approval by another public agency?
_Yes ✓90
Will wastewater other than domestic sewage be generated?
_ Yes v o
TF RESIDENCE FTT,T, OI TT THF, BOX RFI,OW
# People #Bedrooms 3 # athrooms 3t, Garden Tub/Whirlpool es ❑No
Basement: es ❑No Basement Plumbing: 9N es ❑No
IF NON -RESIDENCE FIT. T:, OUT THE BOX BELOW
Type of Facility/Business Total Square Footage of Building # People
# Sinks # Commodes # Showers # Urinals
Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: # Seats
Type system requested: onventional ❑Accepted ❑Innovative ❑Alternative ❑Other.
Water Supply Type: 2Xounty/City Water ❑ New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes [_Qii
If yes, what type?
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that
any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if
the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized Representative
of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules.
I understand that I am responsible for the proper identification and labeling of property lines and comers and locating and flagging
or staking thgj�puse/facjJity location, proposed well location and the location of any other amenities.
Property owner's o Site Revisit Charge
owner's legal representative signature
Date(s):
eliA__ Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No 000 O Account # 3'O��
Revised 11/06 Vj V V Invoice #
9Z�D
I
'A�- . '.�.
PD
Al'1'L.
ENVIRON ,ENTAL HEALTH
DAVIE COUN lY
1=013 SIT' LVALUATION/IAIt'liNUIL•NI' 1'L•flllll'! & ATC
Davie County Health Department
&1YiT011111e17td1)Ve,7X1 Section
P. Dox 040/210 FioapiLal Street
blocksvilie, NC 27028
(33G)751-07GO
d f
J
* * *I1.IPORTANT * * * THIS APPLICATION CANNOT DE PROCESSED UIILESS ALL THE REQUIRED
I11FORMATION IS PROVIDED. Refor to tho INFORMATION DULLET111 for instructiolls.
Jade Associates II, LLC Alan Jones
1. franc to be Dillcd Contac l' 1'crso11
Mailing Address Post Office Box 4062 llon:c
City/:,talc/'LIP
Uinston-Salem, PJC 27115-4062 lluuinc:,s phone (336) 759-9688
___..,__,•_.,,
2. llama on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: IX Site Evaluation i ❑ Ilaprovclnent PerwiL•/ATC LI 80th
4. Syctem to Service: E3 House ❑ Mob.ile Home ❑ DuoineSs ❑ Industry ❑ OLller -_
ti
S. Type system requested: M Conventional ❑ conventional modified ❑ innovative
6. If Residence. a People 4 II Bedrooms 4 II Isatllrocilw; 2.5
bDioliwasher I'JGarbage Disposal nKashing Machino MDascrncnL/1'1m1Jjing ❑Da emenL/no Plumbing
7. If Dusincss/Industry /0L•her: verify type _ II licoplc Il Oink:)
N Commodes Il Showers 11 Urinala II IVa Ler Cooler:.)
IF FOODSERVICE: It ScaLn Estimated Water U::agc (gallons per day) _ _
8. Type of water supply: 1� County/City ❑ well ❑ Colmnunityf45
2. Do you anticipate additions or CXI3:1.115IUlls Uf (lie facility Ulis S)'Stl'lll is ilill'lllfclf to See-vc? ❑ Yes oc1 N11
if )'Cs, What t)'I)C?
***IAMORTANT*** CLI ENTSAlUST COMPL1iTG TIIE lU QUlltL•'D PRO)' WIT 11NF0RMATION RLQUI;S'1'l-"D
BELOW. I:itlicr i PLAT or SITE PLAN r1/USTEESUUdl17TED by (lie client lrith'1'IIIS APPI.ICA'I'ION.
Property Di11lcnsions:
T.ix office 111N: 11
See attached map
5871615955
P1-oilcr(y Address: Road Nallle Beauchamp Road
City/Zip
Advance, 27006
1Vnrl'L Ull(L'CI'IONS (1•1-unl IYludisl'ille) to I'I(()I'h RTN'.
East on Highway 158, turn right onto
Gun Club Road and proceed to the end of
the road, turn left -onto Beauchamp Road
If in a Subdivision provide infurnlation, as fullulvs: and the site is located approximately tc�o
Naulc: Proposed Jade Associates miles down Beauchamp'Road on the right and
left side of the road. 3/8/04
Section: Block.. Lot: 14 Date !ionic corners !lagged:
This is to certify that the infonaa(ion provided is correct to the best of my 1(uowledge. 1 understand lhst .1113' pet llil(s)
issued hcreaf(ei, arc subject to 5u5pe115ion or revocation, if the site plans ul• illtcuded use clnulge, ur if the infurMla(iun
subuli((cd in this application is falsified ur changed. 1,, also, understand that I run 1-eq)unsible fur all charges illc•!c,•rl rl %tour
this application. I, hereby, give consent to (lie Authorized Representative of the llavie Cuuuty 11c:11(I1 I)c ):u•tM c! I1
to cuter upon above described pruperly located in Davie County and url•lied by Jade As s'oc i ates 4 I , LG
to cunduct all lesling procedures is necessary to dc(erl11ine the site suitability.
3/15/04
DATE SIGNATURE
THIS ARLA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of (lie fulluwiq. Existing and prupused
property lines and dinlensions, structures) setbacks, and septic locations).
Silc Revisit CI1a1'ge
Datc(s):
Client Notification Date:
MIS:
Sign given
Arrnnnf Nn
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 INFORMATION
Tax PIN/EH #: 5871-61-5955.14
Subdivision Info: Pro Jade Assoc. Lot # 14
Location/Address: Beauchamp Rd -27006
Property Size: see map Date Evaluated: Q
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS
1
2
3 4 5 6 7
Landscape position
L
Sloe %
7V
900
HORIZON I DEPTH
~ 1t
is
Texture groupG
Consistence
f S
Structure
k
. k
Mineralogy
HORIZON II DEPTH
2
% - 971
Texture group
51CL SAP
t 0
Consistence
r55 5p
`
Structure
C Q
Mineralogy
: 1
HORIZON III DEPTH
Texture groupCL
Consistence
N
CrSl A
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
5
P
LONG-TERM ACCEPTANCE RATE
-p.3
•3�D.3.
SITE CLASSIFICATION: 4S C332�
EVALUATION BY: dlt ),*c
LONG-TERM` ACCEPTANCE RATE. ' •%
s.dNrl 104 Ma4d dloo ..wnd ...w d -.n en Mb Plel wfYd 6-
ero Pp ru N .N -d d eN Um -d
PbnMna Board
rsnbs .M ePPrwd M !Ms -Adh/-Iw. M,wldh,w,l- b tl,r .Wwk-
)wbddhnd rrswdiar- ww otos w,d, s -wn, .-awm 4646
bea^dar7 Nhw -.dd b Mjvct b ahwp. A rwwll,atien M a
aRw Pm —P b M-.. tl- 46&-.07' N ke4dsb.-I eel-.dwlw
d ! -o d d--bpn-14. (SPE PUT BOOK 6. PAGE 65 FOR
lDGllal)
GRAPHIC SCALE
s- M 1
( ON MT)
1 inch - 40 6
b
.ma�,sy�y
'rs� c_biw bpR. ors' W -eI Iain. s..1
NFssYw M _A 4 .aM b -O bN YM
N�rO=.� � µMI N a�M. tlIM meq MOr
MEADOWS EDGE DR.
(PUBUC 50- R/N')
L-01.91
i1-50.00'
Chad &g-552Z1'29'E
ChaN Dht.5&03'
LEGEND
cwh. ll.
• - rw� -en
16
P/L
� EMtR
U
r
I
or.m
p E.1
I 36'E
4. 1/2' bar sd at - W. and Pro unlet Wt ss mA d.
(Md tel eomws
W
I 146.57'
EIR t
6. Zw*n is RssidsnUd AWkWbxd (R -A).
[31
30,127 sf.t
J
7. s.einh.nt cep. and onwr w-dan eanael slnraka.. net .ho.n.
0.69 oc.t
_
0. NC Orifi ti. Wood an GPS onsion d 11/19/04 tied to NCGS (WO49) Fraternity
n
8 M
I�
(Forsyth County) NC Grk NAD 63 (3ans 26, 1996 odi-b—t): N - 631.345.45'- E -
1,602.751.55'. 797.56' (MSU N= 29, Combk d Fader- 0.99993101. PeuUonal
ittb\
t.[--- 0.10'
h
M s
L 30.7r
fa
Grid North h OROV42' countw-elabhs frwn Plot North. Add 00'01'42' to Plot
I
R-23.00'
13
flR
and lkq-533V0'TA'E
Di.t-z&e7'
\\
h
i EIR L-54.06'
R-50Chord 0'
Chord &g-N2T05'46'W
)
&hard Dlet.74.52'
32228 sf.t
1
0.74 ac.t
I 1D unuTr
_
(�EASEIIENT
EIR /
'TIE LME'
/ :So.13'
���RRRRRR 50.00'
Cord Brq.N60T5.41'E
�•
Chord DM -04.52'
�y
3� �b
a
is
NNC Gdd (NAD 53)
�N . 911.75&7('
1.776.310.2¢'
temdrrd Fade -
GRAPHIC SCALE
s- M 1
( ON MT)
1 inch - 40 6
b
.ma�,sy�y
'rs� c_biw bpR. ors' W -eI Iain. s..1
NFssYw M _A 4 .aM b -O bN YM
N�rO=.� � µMI N a�M. tlIM meq MOr
MEADOWS EDGE DR.
(PUBUC 50- R/N')
L-01.91
i1-50.00'
Chad &g-552Z1'29'E
ChaN Dht.5&03'
LEGEND
cwh. ll.
• - rw� -en
M � � PcL
P/L
� EMtR
1. AN distances ars hi—id ground unlm otMr-is. noted.
r
I
or.m
�
EAYIIENT \ �
NOTES
4T
� EMtR
1. AN distances ars hi—id ground unlm otMr-is. noted.
r
I
2. 10' Ub'6ty Eosornorlt Owl the frmt of d lots.
3. Nd a6 (slot" struck— and UM. W -n.
4. 1/2' bar sd at - W. and Pro unlet Wt ss mA d.
(Md tel eomws
S. 20' Omk" Easement is 10' each side of pips, unless ca -fes mtsd.
4
I I
6. Zw*n is RssidsnUd AWkWbxd (R -A).
[31
30,127 sf.t
J
7. s.einh.nt cep. and onwr w-dan eanael slnraka.. net .ho.n.
0.69 oc.t
_
0. NC Orifi ti. Wood an GPS onsion d 11/19/04 tied to NCGS (WO49) Fraternity
(Forsyth County) NC Grk NAD 63 (3ans 26, 1996 odi-b—t): N - 631.345.45'- E -
1,602.751.55'. 797.56' (MSU N= 29, Combk d Fader- 0.99993101. PeuUonal
t.[--- 0.10'
9. Bowing- sha-n on plat an 7's —d to Plot Book 6 O 85, unless othor-bo mtsd.
Grid North h OROV42' countw-elabhs frwn Plot North. Add 00'01'42' to Plot
boorings for grid boorings.
13
:.mwa"`i'`"....:":,""-.'n
D.e.mw Ao 2004
PRELIMINARY
A
NOT FOR RECOROAl10 6..w -
D=. OR BUILDING 3�176
Revision of Lots f4 & f7 of
Phase f
(Plat Book B O f44)
Meadows Edge
a, --
tot 14. Tate ff- Horr - 1"a.
Good Book 624. Pogo 244
PM: 5871627102
Lot 17: Tats Biu Il—. Ina
Dow Book 393. Pogo 293
RN: 5871525048
P/0Plat Book 8 O Page 144
1.43 acres t in 2 Lots
Area by computer
satE TdRN91P 070ay sus bar
1' . b' F—Wglon Daub North Cordlm 12/01/04
. Allied Land Surveying
Co).T,sPA,a.6-Nor
9497
NNoM 32J" `
JCM%ns 246