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199 Meadows Edge Drive Lot 12OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Scott Miller Address: 199 Meadows Edge Drive City: Advance StatefLip: NC 27006 Phone #: (336) 940-6367 Address/Road #: 199 Meadows Edge Drive Advance NC 27006 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: 'Water Supply: PUBLIC 'CDP File Number 194977.1 E8 -160 -AO -012 County I0 Number; Evaluated, For EXPANSION Q Township: Property Owner. Scott Miller Address: 199 Meadows Edge Drive Cty: Advance State2ip: NC 27006 11,�hone #: (336) 940-6367 �erty Location & Site Information Subdivision: Meadows Edge Phase: Lot: 12 Directions Hwy 158 right on Baltimore Rd. left on Beauchamp 'IP Issued by. 2140-Natimons,Robert 'System Classification/Description: 1 TYPE It A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPO OR LESS) 'CA issued by: 2140 - Nations, Robert SaproliteSystem? QYes (30No Design Flow: 4 g 0 *Distribution Type: GRAVITY -SERIAL Pump Required? O Yes QoXo Soil Application Rate: 0 . 3 'Pre Treatment: Drain field Nitrification Field No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: Aggregate Depth: 3 3 3 Sq. ft. 1 1 0 0 ft. Inches O.C. — %Feet O.C. 3 Qlnches (ffeet inches "System Type: Installer: Randy Miller Certification #: 1128 *EH S: 2140 -Nations. Robert Date: 0 7/ 2 3/ a e 1 5 Minimum Trench Depth: 3 6 Inches Minimum Sol Cover. Ara a 4 Inches pp Maximum Trench Depth: '3 6 Inches ®Approv k ,Maximum Soil Cover. 2 4 Inches Is sapproved CDP File Number 194977 -1 S Manufacturer. STB: Gallons: Date: / / *Filter Brand: Yes 0 No ST Marker El Yes 11 No nforced Tank: El Yes El No 1 Piece Tank: El Yes 0 No Manufacturer. W Gallons: Date: / / RiserSealed [] Yes 0 No RiserHeight: El Yes El No (Min.6in.) nforcedTank: El Yes 1:1 No 1 Piece Tank: El Yes E3 No Pipe Size: inch diameter Pipe Length: feet *Schedule: Pressure Rated ❑ Yes 13 No approved fittings ❑ Yes 13 No County ID Number: E8-lMA'-0'2 c Tank Lat. a Long: Installer. Certification fl: *EH S: Installer Certification #: THS: SUDDIV Date: -7) Approv a[ Status.'-":' O Approved 01 Disapproved - .Ina Installer Certification #: *EH S: Date: Approvalstatus 0 Approved 0 Disapproved Pump Type: Installer. Dosing Volume: Gal Certification #: Draw Down: Inches THS: *Chain: Date: Valves Accessible El Yes El No Flow Adjustment Valve El Yes 1:1 No Check -valve El Yes El No Approval Status- - PVC Unions El Yes El No 13- Approved ODis ed aDDF Vent Hole El Yes El No .. ............... . Anti -siphon Hole El Yes El No CDP File Number 194977 - 1 NEMA 4X Box or Equivalent Box 12 inches Above Grade Box Adj, To Pump Tank Conduit Sealed Pump Manually Operable *Activation Method: ❑ Yes ❑ Yes ❑ Yes ❑ Yes ❑ Yes County ID Number: E8-160-Ao-012 Electric EaulDment ❑ No Installer. ❑ No Certification #: ❑ No ❑ No *EHS: ❑ No Date: Alarm Audible El Yes ❑ No`Approval Status , ❑ Approved ❑ Disapproved . Alarm Visible ❑ Yes ❑ No 2140 - Nations. Robert *Operation Permit completed by: /' Authorized State Age .. Date of Issue: 0 7 / a 3 / a to 1 5 Owner/Applicant Signature: This system has been installed in compliance with applicable NC General Statutes: Article 11, Chapter 130A, Rules for Sewage Treatment and Disposal, 15A NCAC 18A.1900 et. Sep., and all conditions of the Improvement Permit and Construction Authorization. This property is served by a TYPE a A. sewage septic system. Rule .1961 requires that a Type NPE ll A. septic system meet the following criteria: Minimum System Review ByThe Local Health Department: NIA Management Entity: OWNER Minimum System Inspection/Maintenance Frequency ByCertifred Operator. NIA Reporting Frequency By Certified Operator: NIA Rule .1961 requires that a Type IV and V septic systems designed for a home/business owner must maintain a valid contract with a public management entity with a certified operatoror a private certified operator for the life of the septic system. Rule .1961 requires that Type VI septic systems designed fora homelbusiness owner must maintain a valid contract with a public management entity with a certified operator for the life of the septic system. Rule. 1961 (2) (e) requires a contract shall be executed between the system owner and a management entity prior to the issuance of an ,Operation Permit for a system required to be maintained bya public or private management entity, unless the system ownerand certified operator are the some. The contract shall require specific requirements formaintenance and operation, responsibilities of the ownerand systems operator, provisions that the contract shall be in effect for es tong as the system is in use, and other requirements for the,continued proper performance of the system. n shall alsobe a condition of the `Operation Permit that subsequent owners of the systems execute such a contract. @Hand Drawing OlmportDrawing .0 **Site Plan/Drawing attached.** OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC Drawing Drawing Type: Operation Permit CDP File Number: 194977 -1 County File Number: E8'160-Ao-012 27028 Date: / l Olnch Scale: QBlock ON/A C vel R i ` i ll- �I i Illli SI I i SIS I II 1 it I I I S i i� IJ Applicant: Address: City: State/Zip CONSTRUCTION AUTH TDRWATION Davie County Health Department 210 Hospital Street P.O. Box 848 For Office Use Onlv "CDP F ile N um ber 194977-1 County ID Number. Es -160 -AO -012 Evaluated For: EXPANSION Township: MOCkSVllle NC 27028 rrtKMI i VAtJu VN i IL: Phone: 336-753-6780 Fax: 336-753-1680 0 7/ 0 8/ a 0 a 0 Scott Miller FAddress: wner: Scott Miller 199 Meadows Edge Drive 199 Meadows Edge Drive Advance Advance NC 27006 NC 27006 Phone #: (336) 940-6367 FCO Address/Road #: 199 Meadows Edge Drive Advance NC 27006 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: *Water Supply: PUBLIC Phone #: (336) 940-6367 Subdivision: Meadows Edge Phase: Lot: 12 Directions Hwy 158 right on Baltimore Rd. left on Beauchamp Dann 4 M1 Minimum Trench Depth: a 4 Inches Site Classification: Provisionally Suitable Saprolite System? OYes ®No Minimum Soil Cover. 1 a Inches Design Flow: 4 8 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 - 3 Maximum Soil Cover: a 4 Inches *System Classification/Description: *Distribution Type: TYPE 11 A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: _ Gallons *Proposed System: 25% REDUCTION 1 -Piece: DYes ONo Pump Required: DYes ONo OMay Be Required Nitrification Field 3 3 3 Sq. ft. Pump Tank: Gallons No. Drain Lines 1 1 -Piece: DYes ONo Total Trench Length: 1 0 0 ft GPM vs— ft. TDH Trench Spacing: _ 9 Inches O.C. Dosing Volume: _ Feet O.C. Gallons Trench Width: 3 QInches _ O Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS -1 OTS -11 1\ Septic Tank Installer Grade Level Required: 01 OI! 0111 OIV Dann 4 M1 CDP File Number 194977 -1 County ID Numbe : E8 -160 -AO -012 ❑ Open Pump System Sheet Repair System Required:@Yes ONO ONO, but has Available Space /Repair System Trench Spacing:Inches O. 9 *Site Classification: Provisionally Suitable — Feet O.C. Trench Width: Qinches 3 Design Flow: 4 8 0 — V Feet Aggregate Depth: Soil Application Rate:0 3 inches .� Minimum Trench Depth: a 4 *System Classification/Description: Inches TYPE 11 A. CONV SYSTEM (SINGLE-FAMILY OR480 GPD OR LESS) Minimum Soil Cover. 1 a Inches Maximum Trench Depth: 3 6 'Proposed System: 25% REDUCTION Inches Maximum Soil Cover: a 4 N ilrification Field 1 6 0 Inches Sq. ft. No. Drain Lines *Distribution Type: GRAVITY - PARALLEL (eq. d -box) 4 Total Trench Length: 4 0 0 ft Pump Required: Oyes QNo OMay Be Required IN, Pre Treatment: ONSF OTS -1 OTS -II "Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. "Permit Conditions The issuance of this permit bythe Health Department in no wayguarantees the issuance of other permits. The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. This Authorization for Wastewater System Construction shall bevatid for a person equal to the period of validity of the Improvement Permit, not to exceed five years, and maybe issued atthe sametime the Improvement Permit Issued (NCGS 130A -336(b)) If the installation has not been completed during the period of validity of the Construction Permit, the Information submitted In theapplication for a permit or Construction Authorization is found to have been Incorrect, falsified or changed, or the site Is altered, the permit orConstrucWn Authorization shall become invalld, and maybe suspended or revoked (.1937(g)). The person owning or controlling the system shall be responsibleforassurirg compliance with the laws, rules, and permit conditions regarding system location, Installation, operation, maintenance, monitoring, reporting and repair (1938(b)). Applicant/Legal Reps. Signature Required? Oyes ONO Applicant/Legal Reps. Signature: Date: , / / * 2140 - Nations, Robert 0 7 / 0 8 / a 0 1 5 Issued By: Date of Issue: - . PW Authorized State Agent: Malfunction Log Oyes @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie. County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Drawing Type: Construction Authorization CDP File Number: 194977 - 1 County File Number: E8-160-Ao-012 Date: 07/08/2015 Q Inch Scale: OBlock QN/A ---- - - - --- ...... . -Fr7l-�4 - - ----- --- ---- - .... .. ....... ... ... ..... . . . .. ........... . ... -- - - ------ - ----- . ........... . ----- - -- i i I ��I i . . ... .... . . i LIOp � � --------- ---- y�J I� - ---------------- it------ i ... ...... .......... . .... it 1 0 - ------------- .................. . .. . .. .... . . . .. ............ II `UOI. Yd ....... .. . .. . .... .... . ------ II ...... IIA .... .. . .... '.. i i —I I_ CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville C 27028 Click below to Import an Image from an external location: Drawing �r CDP File Number: 194977 - County File Number: E8-16Q-Ao-012 Date: .0 7 1 08 / 2 0 1 5 ;Construction Authorization 'I , �-3- 1y� APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health p�``�P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/ Fax (336) 753-1680 Ap�icationFor:ite Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Type of Application: ❑New System ❑Repair to Existing System 1*xpansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions" R�CIVE APPLICANT INFORMATION �/� ame to be Billed C,O� Lt._I_ • Contact Person SLO t --1 r' �^ LL �tDt Billing Address q 1J 2e, w L t' e r • Home Phone ^ City/State/ZIP 1 Business Phone 3,7b -312_— !E2.0. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip _ 6 -7u4 2„Q PROPERTY INFOKMAIION Date House/pacinty corners riaggeo NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is va�Id for 60 months with site plan, no expiration with complete plat.) b' y 9- `(/� Owner's Name J C i �- Pho e I�iumber33 Owner's Add ress /Vlit hil }— City/State/ ip c(Jcn[—�. �3 Property Address ocJ ^ City Z%�1a b Lot Size Tax PIN# L'3_160 -AO -0171 / c —1 6 0' O �' Q Subdivision Name(if ap➢I ab _ Section/Lot# I Directions To Site: p Q `yes", be If the answer to any of the following questions is supporting documentation must attached, G � Are there any existing wastewater systems on the site? )dyes ❑No Does the site contain jurisdictional wetlands? ❑Yes I , „ /� t p Q Are there aneasements or right-of-ways on the site? ❑Yes o `/ (Jj/If, ,( KNo `� Is the site subject to approval by another public agency? ❑Yes IWO , %�� ✓) Will wastewater other than domestic sewage be generated? ❑Yes o 1F RESIDENCE FILL OUT THE BOUELOW # People� # Bedroom # Bathrooms Garden Tub/Whirlpool es ❑No Basement: nY_'es ❑No Basement bins: &Ye_s ❑No IF NON -RESIDENCE FILL 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: Xconvcntional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: IXCounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or exp .qns of the fa�ility this sys m int e t se e? ji Y s ❑ No If yes, what type? W C(1`� NA T1 �' � OR in,. A&Is 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 Represent ive of the Davie County He Department to conduct necessary inspections to determine compliance with applicable laws d rule . I understand that I pirr ibie for the proper identification and labeling of property lines and comers and locatin ag in o mg ity location, proposed well location and the location of any other amenities. er's or owner's legal representative signature Site Revisit Charge Date(s): 62&)I Client Notification Date: Date EHS: Sign given ❑Yes ❑No Revised 11/06 Account # 1 �� Invoice # bn i 20' Public ' 1.24 acres t oy 9 4L . Drainage Easement F' A A 102.50' _ 77. y0 y r � 10' Utility Eosement — 92 CH N ss�9• �1��eh 'I n Contro- lic 50' R/W), 27' BC—BC ComerlN 81 44 41" WR Ss 3 /y 1 1 r- em r S 89'44'36" E?8Q 00 63 1.20 acres t µ U r —10 Utility Eosement — _ Ra ? 41 m I 146.87' S 63 3 p 3 OO 68 29 O ° oti � �m N i>� ice_ °nI , , \ e rn off, toof 15 I �� 12 . y N 0 N - 12' LOCUST TREE Nur) N 0.75 acres t O N / T M 3 � 0 0.69 acres o t h � , N I 0.93 acres v_ o6,42 W N S 62'20'36' E to 5 -7-5.��-0G� S 89'01'11" E S 89'44'36" E 1l IN Oil( E 260.63' O� l f /\ lC V 146.87' �S ' j �- Ref. IRS0., O? s ,o70, 79. p of20' Pubic Oe. 1 *D-;—g,a N D -;—g, X cut on Lis 0.69 acre f top of pipe o •T \ as °'v! caa Ref. IRS, \ 01. 0 r \ 17 moo. � o/s 10' 'yam see Sheet 2 of 2 0.74 acres 40 n t^ io ro' !O. C i l % 0166,41. Sheet 2 of 2 onxxn X\, I, Richard P. Bennett, certify that this plot was drawn under m supervision from an actual survey made under my supervision rdead description recorded in Book as noted, Page , etc.) (other); that the boundaries not surveyed are clearly Indicated as drawn from information found in Book as noted Paiat the ratio of precision as calculated is 1:10,000; that this as accordance with G.S. 47-30 as amended. witness my original ar�1(ire j r and seal pC(•2� • "lg ' f December A.D. 2004 .ate• y<: 6�s ' i �•SZo _.O'.� /-Surveyor 0 Phase 9 on Sheet 1 of 2 Meadows Edge Sc Owner, Jade Associates II, LLC W 1W. 32nd Street Wihston—Salem, NC 27115 phone (336) 759-2580 P/0 County PIN: 5871615955 P/0 Parcel Number E800000O02 P/0 Deed Book 540 ® Page 336 30.64 acres t in 24 Lots Average Lot size = 1.28 acres f 32.74 acres t Total Areas by computer SCALE TOWNSHIP COUNTY STATE DATE 1" = 100' Farmington Davie North Carolina 12/01/0 suIwEYEo: Allied Land Surveying Co., P.A. ,,O.NO. Cr` 1 1 _.__. - r,____.. — x.11 Oda • ' DAVIE COUNTY HEALTH DEPARTMENT ' 16 Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ��610 Account M 990002436 Billed To: Darren Burke Constr. Reference Name: Proposed Facility Residence ATC Number: 4211 Tax PIN/EH #: 5871-72-0226.12 DB Subdivision Info: Meadows Edge Lot # 12 Location/Address: Meadows Edge Dr. -27006 Property Size: see map ecc pted SystemsNmay also'be u9sJ 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 . CT I19 0 Sewage Trea ent and Disposal Systems). THIS AUTHORIZATION FOR WASTEW S=LI-A PERIOD OF F VE YE Environmental Health Specialist's Signature: iDate: sw =0 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. ,-,rVr1-e44 �a �rpo - ewelro 2 )�K r F Septic System Installed By: 4 t/ Environmental Health Specialist's Signature: YCi° Date: / o DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002436 Billed To: Darren Burke Constr. Reference Name: Proposed Facility Residence ATC Number: 4211 /e./2�—vS Tax PIN/EH #: 5871-72-0226.12 DB Subdivision Info: Meadows Edge Lot # 12 Location/Address: Meadows Edge Dr. -27006 Property Size: see map **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 #People #Bedrooms #Baths Dishwasher: 13 Garbage Disposal: ❑ Washing Machine: Elr— Basement w/Plumbing: d Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size O.T� 0�'Type Water Supply Design Wastewater Flow (GPD) Site: NewRepair ❑ System Specifications: Tank Size AL. Pump Tank GAL. Trench Width Rock Depth 1 Z2' Linear Ft.� , As stated in 15A NCAC 18A.1969(5) Other: £tc�Tli� accepted Systems may also be usead Required Site Modifications/Conditions: 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.**** r Environmental Health Specialist's Signature: DCHD 05/99 (Revised) -j Ttgj Po e T' CAA P` Date: Co N0.77 acres L 9• C �s o3�y 10 1.24 acres f �1 alp 11 1.20 acres f 100 �S 62020'36" E 53.93' �� 6 t Eos Ref. IRS jS O /xO,20' I s'> 79� h n 12 0.93 acres t _ _., Ref. IRS, o 1R o/s 42' D 0 F+ , rC S 89601 111 " E 260.63' X/ \/\/ \' > /\ Sep 19 05 01:56p Darren Burke Construction 336 778 0436 • Jun•IO 03 11_14a davia county envhoalth 33JS 751 0766 P.2 APPMJJON (flit SIZE WALtJ0.TtUN/1ll MYM Mi PMff A, ATC Davie Ctwrdy Health DeRadn=l fiW&Vomea Mulft seiorl m P.O. Haut 9,1e/210 Nospital 6treet '7Si Mocksv131e, DTC 27828 (336)751-87io T1 owej p yi•awe 7KES APPLXCJt:I11M CUR= J18 PROCESS" 6n,63S dLT. T13E BE(JUZABD ImpOatt MIT IS PROVIDED. Refftr tO the/ffi'CMWLCH PULLEM for anatructioua. 1. Mass to he Jtilled� �l-('f�:� �>LJ 1'kk{ `oeotxc naso* ,�Qrr/� G'�h--._.- ..• -•-• ending A"cesa �7 �n �b/ CFLrrr�cn�Dra,��jt a0% C i- j o� amPu mo ma. _ 766 n �b/sraterar C ! PWL' S A)rl a-100%. P (� n 2. 70r. on Pesait/A2C if Dilf r•nf than X.m.9 Ldd"• 'L•LC.—A--�� 2. hpPllrttian lbra Site 3ealration �[.Yapsovemont Hermit/ATC �. SYaoo to sK.seoc �Yo/nne 13 mobile umne 0 nuainess 0 IadustrY D Other g• �W eyst� eryueotedc 76�faoawatiowal (3 eoarmttona2 soaitiod 11 iooaratiwe ^ J f. If Realdance: i paopla 3 4 Dedro=9 _a_ a batbrocros Xr VOODS 9=cs. 0 344tie itat1mated avatar Usage taalloam oar dry) a. 2m of aorsr ooPVl7 Cwtity/City Cl xnll D co • •• n: ty a. m You astictpate addittoam or expansions of the facility 613 Systm is luteuded to smEl 0 Yes Ka Jfyts, V&A type* r••!1/TOICT.(M s'& CUarsblf8rw&Lr rre7im REQUIRED PYDJ' m ENE`aRMAnm REQuEs i ) lH�DY� CftYeral'LATor51PEN.1NjrWrAESUHWn7ZVb7llltecIIat wiWTHJSAPt[ 0070K PropertyDlmar. X F1 x '+�REC71lNlS (rrow l�i.ai5t�7t) to PUUI•t tr To:c Office 1MPt: Jr PtW"Address: Bead Name cilyrzip It in a Subdivision provide h2lim tar_i0n, 2S lollOW f^ �� tvataC g• Section: Block + t� � Date hoaae comets lbwd: -! • 16 • r) 5 This is to eerft tb at theinformadwo prawMed is CwTWt t* the best *TIDY ka*wlcd6c. 1 anda'stasd that am perntit(s) Issued bertsign rat: subject to susmoom or moenuaat, U the site plans or intended use clonge. or if the i*larfoull" submitted ie psis applit2don is faldlied ar ehangod abet raJorrtaoJtLrll sat rrspaSuFblejer oil etimges Soeeae+l/rao� Mus appUQfeiL 1, hereben y, give const to the AnUaorized Rcpreseolatirt of the Dnvic�County Ef Deport e -- (a Mier upon 2b*%e described property lomtd in Davie CDaaty and owned by (< )Ot / �rA, to eomdact aR testinres g proeedaas Doeesary to delermlee the sate suilabi y . r lei-�C, DATE SIGNATURE TIM A=& property Uses sad dlmcodens, slmclnres6 ScUmbs, and W49C lontbas). Site Revisit Chartc Dataa): (,Bent motittcatian Data E13S-- sip th—Account No. oL- Y 3 0, Rl vised DCHD (65M lovolce No. ti�C7 Y v e iip 2005 �RONM DAA£ 0 N� 1(7H 11 of S O L" ,-/-)y ' me � � yiaPa+.1_ ` �� Baymmt/Fiu•6iati t3Yaro L/- tlu.taiag 7. u aualaw.s/Zaduotry /Otter:.orltY t7pw a mole a sinks -- I Q®d•• a sba . a *rime. a n.trr C—lex _ Xr VOODS 9=cs. 0 344tie itat1mated avatar Usage taalloam oar dry) a. 2m of aorsr ooPVl7 Cwtity/City Cl xnll D co • •• n: ty a. m You astictpate addittoam or expansions of the facility 613 Systm is luteuded to smEl 0 Yes Ka Jfyts, V&A type* r••!1/TOICT.(M s'& CUarsblf8rw&Lr rre7im REQUIRED PYDJ' m ENE`aRMAnm REQuEs i ) lH�DY� CftYeral'LATor51PEN.1NjrWrAESUHWn7ZVb7llltecIIat wiWTHJSAPt[ 0070K PropertyDlmar. X F1 x '+�REC71lNlS (rrow l�i.ai5t�7t) to PUUI•t tr To:c Office 1MPt: Jr PtW"Address: Bead Name cilyrzip It in a Subdivision provide h2lim tar_i0n, 2S lollOW f^ �� tvataC g• Section: Block + t� � Date hoaae comets lbwd: -! • 16 • r) 5 This is to eerft tb at theinformadwo prawMed is CwTWt t* the best *TIDY ka*wlcd6c. 1 anda'stasd that am perntit(s) Issued bertsign rat: subject to susmoom or moenuaat, U the site plans or intended use clonge. or if the i*larfoull" submitted ie psis applit2don is faldlied ar ehangod abet raJorrtaoJtLrll sat rrspaSuFblejer oil etimges Soeeae+l/rao� Mus appUQfeiL 1, hereben y, give const to the AnUaorized Rcpreseolatirt of the Dnvic�County Ef Deport e -- (a Mier upon 2b*%e described property lomtd in Davie CDaaty and owned by (< )Ot / �rA, to eomdact aR testinres g proeedaas Doeesary to delermlee the sate suilabi y . r lei-�C, DATE SIGNATURE TIM A=& property Uses sad dlmcodens, slmclnres6 ScUmbs, and W49C lontbas). Site Revisit Chartc Dataa): (,Bent motittcatian Data E13S-- sip th—Account No. oL- Y 3 0, Rl vised DCHD (65M lovolce No. ti�C7 Y v e iip 2005 �RONM DAA£ 0 N� 1(7H 11 of S O L" ,-/-)y ' me D �C�o�E 1�1'! 1 ENVIRONMENTAL HEALTH DA"'!Ecot tTY 11:011 SITE EVALUATION/14111 OV641L•NT 1'L•liflllT & ATC Davie County Health Department f(1Vi/'0/1/Ileylta/Heap/i Section .0. Dox 848/210 IiospiLal Street rlocksville, NC 27020 (33G)751-0760 ***IMPORTANT*** THIS APPLICATION CANNOT DL PROC'ESSE'D UIILESS ALL 1'IIL•' REQUIRL;D I I1IFOR11ATION IS PROVIDED. Refer to tale INFORMATION DULLETIN for inaLruCtiorlD. I'r FOODSERVICE: 11 SCaLII Estimated Water U: aqC (gallons per day) 8. Type of water supply: In County/City ❑ well ❑ ColmuuuiLy�v 9. Do you anticipate additions or C\IT:Ul5i0115 of file f:ldlity this S)'SM11 IS lll(C11(IC(I WSCl'1'L•'! 1:1YCS (Yv No If yes, what O-I)C? ***IAII'0J?7AiYT*** CLIIN'1'SIl1USTCOAIPLGTG'fllE Ill;QUIRL"D PROMI(TY INFORMATION ION 1tliQllliS'I'1SU A ` IIELOII'. Ei(hera PLnTorSITE PLAN d1 UST 11ESUllr1!!T%LU tJy (he client lrilll'1'1115,11'I'LIC�1'1'ION. PruperO. Dimensions: See attached map WRITE* DIRLCTIONS (I'runl MucL'svillc) to 1'1(()I'hRTV: 'f.0 Office PIN: Il 5871615955 East on Highway 153, turn right onto Property Address: Road NaMlc Beauchamp Road Gun C l Ub Road and proceed to the end of City/Gip Advance, 27006 the road, turn left -onto Beauchamp Road If ill a SUbdiY25ioll pr0Y1dC 1llf U1'111afioll, as 1701101YS: Name: Proposed Jade Associates Scc(ion: Bloch:12 Lot: and the site is located approximately Wo ni1es down Beauchamp Road on the right and left side of the road. 3/8/04 Dale honk corucrs flagged: This is to certify that the i iforulation provided is correct to the hest of Mly kuowlcdgC. I ulldcrstalld that :1113, perlili((s) issued hcrcafler arc subject to suspension or revoca(iou, if the site plans or in(euded use change, or if file iuforula(ioll subnli(ted in (his application is falsified or changed. 1, also, 11111terstillul that l uul re3punsible fur till charges inc•tr1•rcit front this upplicutiult. I, Hereby, give consent to the Authorized Represellta(iye of (Ile 1):Ivie Cutill O, 11e:1181 1)clm1 111{LL 1 (o enter upon abo�'c described pruper(y located ill Davie Comity and uwned by ,lade Associates 11 L C to cunduct all teslhlg pr0cedu1c5 a5 Accessary to delerluine the site suitabili(1'. 3/15/04 DA'11 SICNA"I'URE THIS ARLA MAY BE USED FOR DRAWING YOUR SI1'E PLAN (Iliclude all of file fulluivillg: Existing and prupused property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Dalc(s): Clicul Notific;Iliuii Dale: EIIS: Sigil given Arrnnnt No Jade Associates II, LLC Alan Jones 1. t7ama to be Dilled CUntaCt Parson Post Office Box 4062 Mailing Address Iloluc Winston-Salem, HC 27115-4062 (336) 759-9688 Cl ty/v Ca CC/LIP 11UJlIlUD� 1'11U11C 2. llama on Permit/ATC if Different than Above Mailing Address City/StaLe/Zip 3. Application For: Site Evaluation ❑ IluprovcmciiL• PcruliL/ATC Ll nuL'h 9. Syctem to Servicc: ® 1I0112e ❑ 2d0bile 1I0IIle ❑ 1jUSiI1eC17 ❑ IliduSLry ❑ OLhcr ti 5. Type system requested: M Conventional ❑ conventional modified ❑ innova Llvu 6. If Residence: 11 People 4 11 Bedrooms 4 II IlaLllroolm; .2.5 Liahwdsher Larbage Disposal nviashing Machino MDascmcnL/Plwnbing [Ilia scmenL/llu Plwubim) 7. If Dusincaa/Industry /OLhor: verify type _ 11 People 11 A Coulcwdes 11 Showers 11 uriiialu 11 WaLei: CoolLv:1 I'r FOODSERVICE: 11 SCaLII Estimated Water U: aqC (gallons per day) 8. Type of water supply: In County/City ❑ well ❑ ColmuuuiLy�v 9. Do you anticipate additions or C\IT:Ul5i0115 of file f:ldlity this S)'SM11 IS lll(C11(IC(I WSCl'1'L•'! 1:1YCS (Yv No If yes, what O-I)C? ***IAII'0J?7AiYT*** CLIIN'1'SIl1USTCOAIPLGTG'fllE Ill;QUIRL"D PROMI(TY INFORMATION ION 1tliQllliS'I'1SU A ` IIELOII'. Ei(hera PLnTorSITE PLAN d1 UST 11ESUllr1!!T%LU tJy (he client lrilll'1'1115,11'I'LIC�1'1'ION. PruperO. Dimensions: See attached map WRITE* DIRLCTIONS (I'runl MucL'svillc) to 1'1(()I'hRTV: 'f.0 Office PIN: Il 5871615955 East on Highway 153, turn right onto Property Address: Road NaMlc Beauchamp Road Gun C l Ub Road and proceed to the end of City/Gip Advance, 27006 the road, turn left -onto Beauchamp Road If ill a SUbdiY25ioll pr0Y1dC 1llf U1'111afioll, as 1701101YS: Name: Proposed Jade Associates Scc(ion: Bloch:12 Lot: and the site is located approximately Wo ni1es down Beauchamp Road on the right and left side of the road. 3/8/04 Dale honk corucrs flagged: This is to certify that the i iforulation provided is correct to the hest of Mly kuowlcdgC. I ulldcrstalld that :1113, perlili((s) issued hcrcafler arc subject to suspension or revoca(iou, if the site plans or in(euded use change, or if file iuforula(ioll subnli(ted in (his application is falsified or changed. 1, also, 11111terstillul that l uul re3punsible fur till charges inc•tr1•rcit front this upplicutiult. I, Hereby, give consent to the Authorized Represellta(iye of (Ile 1):Ivie Cutill O, 11e:1181 1)clm1 111{LL 1 (o enter upon abo�'c described pruper(y located ill Davie Comity and uwned by ,lade Associates 11 L C to cunduct all teslhlg pr0cedu1c5 a5 Accessary to delerluine the site suitabili(1'. 3/15/04 DA'11 SICNA"I'URE THIS ARLA MAY BE USED FOR DRAWING YOUR SI1'E PLAN (Iliclude all of file fulluivillg: Existing and prupused property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Dalc(s): Clicul Notific;Iliuii Dale: EIIS: Sigil given Arrnnnt No 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: On -Site Well PROPERTY INFORMATION Tax PIN/EH #: 5871-61-5955.12 Subdivision Info: Pro Jade Assoc. Lot # 12 Location/Address: Beauchamp Rd -27006 see map Date Evaluated: �t Community Evaluation By: Auger Boring Pit 611._In4 c Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L L Cav Sloe % Z47f1p & ZO HORIZON I DEPTH O -2 v^ C C— I Texture group IL_ G G Consistencer'. Structure l Mineralogy1: 1 . I HORIZON II DEPTH - 2�' -'3 Texture group; c. + Consistence % Structure ICS Mineralogy HORIZON III DEPTH - E- =t5 Texture group 12 540 aio 5 L Consistence Structure 5 e - Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE t) S CLASSIFICATION P - sqou —5 LONG-TERM ACCEPTANCE RATE b•3 D ^� SITE CLASSIFICATION: t ✓ ( ?J 130 - sHaLwi LONG-TERM ACCEPTANCE RATE: 0'3 REMARKS: Ct l X10 FES A`''(f-'-V- ttBl,U �It. LEGEND Landscape Position EVALUATION BY: ' �� " (-Jt- Joh" -.- 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)