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132 Alvis Trail OPERATION PERMIT or ice se n v Davie County Health Department *CDP File Number 192206-2 210 Hospital Street P.O.Box 848 County ID Number- '` Mocksville NC 27028 Evaluated For; NEW Phone:336-753-6780 Fax:336-753.1680 Township: Applicant: Duane G. Longworth Property owner: Duane G. Longworth Address: 219 Mumford Drive Address: 219 Mumford Drive City: Mocksville City: Mocksville State)Zip: NC 27028 State2ip: NC 27028 Phone#: (336)391-9111 Phone#: (336)391.9111 Propertv Location & Site Information rGeAddrdess/Road 9: Subdivision: Phase: Lot: ren-erivevance NC 27006 Directions Structure: SINGLE FAMILY Hwy 158, second Redland road, beside Andy's County Store, turn left then right on Gordon Rd near of Bedrooms: 3 234 #of People: *Water Supply: PUBLIC *IP Issued by. 21ao-Nations,Robert *System Classification/Description: TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140-Nations,Robert Saprotite System? OYes 1)No Design Flow: 3 6 0 *Distribution Type: GRAVITY-PARALLEL(eq.d-box) PumpReQNo? OYesSoil Application Rate: 0 a 7 5 *pre Treatment: Drain field Nitrification Field 1 3 0 9 Sq. ft. *System Type: INFILTRATOROUICK4STANDARD No. Drain Lines 3 Installer: Sherman Dunn Total Trench Length: 3 a 7 ft- Certification#: 2702 Trench Spacing: — _ ()Inches t O.C.O.C. 'EHS: 2140•Nations,Robert Trench Width: 3Inches gFeet Date: 0 4 / 0 5 / 2 0 1 6 Aggregate Depth: inches Minimum Trench Depth: 3 6 • Inches Minimum Soil Cover, a 4Inches ;ApprovatStatus Maximum Trench Depth: 3 6 ®=Approved LO Disapproved; Inches Maximum Soil Cover. 2 4 Inches CDP File Number 192206 . 2 Septic Tank County ID Number: 4 Manufacturer. Shoat Lat. STB: 760 Long: Gallons: 1000 Installer. Sherman Dunn Date: 0aI 01 / aI� 16 Certification#: 2702 *EH S: 2140-Nations,Robert *Filter Brand: POLYLOK PL-122 With Pipe Adapter ST Marker: El Yes 2 No Date: / a 0 1 6 5 / Reinforced Tank: El Yes ® NO �` APprovallafus ; 1 Piece Tank: ❑ Yes C7 No ® Approved❑ , Dtsapproved Pump Tank Manufacturer. Installer. PT: Certification#: Gallons: *EH S: Date: / Date: RiserSealed ❑ Yes ❑ No RiserHeght:"❑ Yes - ❑ No (Min.6 in.) Appraval Status Reinforced Tank: El Yes ❑ No p ApprovedO Dtsapproved 1 Piece Tank: ❑ Yes ❑ No Supply Line rPipe Size: inch diameter Installer: pe Length: feet Certification#: *Schedule: THS: Pressure Rated ❑ Yes ❑ NO Date: / Approved fittings ❑ Yes ElNo Aypprovalstatus ❑ App>ovedQ=Disapproved f-� Pump u e Pump Type: Installer. Dosing Volume: — Gal Certification#: Draw Down: Inches *ENS. *Chau: Date: Valves Accessible ❑ Yes ❑ NO Flow Adjustment valve ❑ Yes ❑ No Check-valve ❑ Yes ❑ No Approval Status, PVC unions El Yes ElNo Q Approved❑ Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole El Yes ❑ No CDP File Number 192206 -2 County ID Number: Electric Equipment NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer. Box 12 inches Above Grade ❑ Yes ❑ NO Certification#: Box Box Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ NO *EHS: Pum p M an ually 0 perable ❑ Yes ❑ No *Activation Method: Date: / Approval Status Alarm Audible El Yes ❑ No ❑ Approyed0, Disapproved' Alarm Visible ❑ Yes ❑ No 2140-Nations.Robert *Operation Permit completed by: Authorized State mz �� Date of Issue: 0 4 / 0 5 / 2 0 1 6 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. Seq..and all conditions of the Improvement Permit and Construction Authorization.This property is served by a TYPE II A. sewage septic system. Rule.1961 requires that a Type TYPE II A septic system meet the following criteria: Minimum System Review ByThe Local Health Department: NIA Management Entity: OWNER Minimum System Inspection/Maintenance Frequency ByCertified Operator. NIA Reporting Frequency By Certified Operator: NIA Rule.1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract with a public management entitywkh a certified operatoror a private certified operator forthe life of the septic system. Rule.1961 requires that Type VI septic systems designed fora home/business 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 ently prior to the issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the system owner and certified operator are the same. The contract shall require specific requirements for maintenance and operation, responsibilities of the owner and systems operator,provisions that the contract shall be in effect for as long as the system is in use,and other requirements for the continued proper performance of the system. It shall also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. @Hand Drawing OlmportDrawing **Site Plan/Drawing attached.** OPERATION PERMIT 192206 -22 Davie County Health Department CDP File Number: 210 Hospital Street RO.Box EWA County File Number: Mocksville NC 27028 Date: Olnch Drawing Drawing Type: Operation Permit Scale: OON A k { I I ---------------------- 0 ------------------ ' 4� s..�,l _�..! `� .-''�"� '`� cA► .cam CA � I i - - - o 0 CONSTRUCTION For Office use Only, -. AUTHORIZATION 'CDP Fite N um tier 1922,06-2 t Davie County Health Department .County ID Number 210 Hospital Street Evaluated For. NEW P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone:336-753-6780 Fax:336-753-1680 0 9 / 1 5 / a 0 a 0 r pplicant: Duane G.Longworth Property Owner. Duane G.Longworth ddress: 219 Mumford Drive Address: 219 Mumford Drive City: Mocksville City: Mocksville State/Zip: NC 27028 State[Zip: NC 27028 Phone#: (336)391-9111 Phone#: (336)391-9111 Property Location Si We Information Address/Road#: _S tbdivision: Phase: Lot: .�413Z A vis /ra:�/ Advance NC 27006 Directions Structure: SINGLE FAMILY Hwy 158, second Redland road, beside Andy's County Store, turn left then right on Gordon Rd near 234 #of Bedrooms: 3 #of People: "Water Supply: PUBLIC System Specifications Minimum Trench Depth: a 4 Site Classification: Provisionally Suitable Inches Minimum Soil Cover. 1 a Saprolite System? QYes QNo Inches Design Flow: 3 fi 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 2 7 5 Maximum Soil Cover: a 4 Inches 'System Classification/Description: "Distribution Type: GRAVITY-PARALLEL(eq.d-box) TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: Gallons 'Proposed System: 250/a REDUCTION 1-Piece: QYes ®No Pump Required: QYes QQ No Q May Be Required Nitrification Field 1 3 0 9 Sq.ft. Pump Tank: Gallons No.Drain Lines 3 1-Piece:QYes QNo Total Trench Length: 3 a 7 ftGPM—vs— ft. TDH Trench Spacing: — 9 @Inches O.C. Dosing Volume: _ Gallons Feet O.C. Trench Width: Inches 3 . Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-11 Septic Tank Installer Grade Level Required: 01011 0111 01V Dann 1 of Z CDP File Number 192206-2 County ID Number. ❑ Open Pump System Sheet Repair System Required:@Yes ONo ONo, but has Available Space rDesign System Trench Spacing: Inches 0. ification: Provisionally Suitable 9 0 Feet Q.C. Trench Width: Inches w: 3 6 — 3 Feet Soil Application Rate: 0 a 7 5 Aggregate Depth: inches Minimum Trench Depth: 2 4 "System Classification/Description: Inches Minimum Soil Cover. 1 Inches Maximum Trench Depth: 3 "Proposed System: Inches Nitrification Field 1 3 0 9 Sq.ft. Maximum Soil Cover: a 4 Inches No. Drain Lines 3 "Distribution Type: GRAVITY-PARALLEL(eq.d-box) Total Trench Length: 3 2 7 ft Pump Required: Oyes ONo ()May Be Required Pre Treatment: ONSF OTS-1 OTS-11 *Site Modifications No grading or construction activity is allowed in areasdesignated for system and repair without approval of Health Department. "Permit Conditions The issuance of this permit bythe Health Department in no way guarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. This Authorization forwastewater System Construction shall be valld fora person equal to the period of validity of the Improvement Permit:not to exceed five years,and may be lssued at the sametime the Improvement Permit Issued(NCGS 930A-336(b)}If the Installation has not been completed during the period of validity of the Construction Pemtit;the information submitted in the application for a permit or Construction .. Authorization Is found to have beet Incorrect,falsified or changed,or the sits is altered,the permit orConstrurtion Authorization shell become Invalid,and may be suspended or revoked(.1837(g)).'The person owning or controlling the system shall be responsible forassuring compliance with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance;monitoringreporing and repair (1938(b)). - Applicant/Legal Reps.Signature Required? OYes ONo Applicant/Legal Reps.Signature- Date:, 1 2140-Nations,Robert 0 9 / 1 5 1 2 0 1 5 Issued By: Date of Issue: Authorized State Age Malfunction Log Oyes 'g @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION 192206-2 Davie County Health Department CDP File Number: 210 Hospital street P.O.Box M County File Number. Mocksville NC 27028 Date: 0 9 / 1 5 / 2 0 1 5 O inch Drawing Drawing Type: O Construction Authorization Scale: O�A k ' I I fG . 1 i I 1- Y I 4` 1 G I CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: 192206-2 P.O.Box 848 Mocksville NC 27028 County File Number: Date: 09 / 15 / 2015 Click below to Import an image from an external location: Drawing Type:Construction Authorization IMPROVEMENT PERMIT * . For.officeuseonly CDP File Number 192206- 1, Davie County Health Department 3 County ID Number:':. . • 210 Hospital Street - w P.O.Box 848 'Evaluated For. NEW Mocksville NC 27028 Township: Phone:386-753-6780 Fax:336-753-1680 PERMIT VALID UNTIL: 4/27/2020 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be Issued with this Improvement Permit. Applicant: Duane GI. Longworth Property Owner. Norma Jean Dunn Address: 219 Mumford Drive Address: 234 Gordon Drive City. Mocksville City: Advance State/ZiX NC 27028 State/Zip: NC 27006 Phone#: (336)391-9111 Phone#: (336)998-4375 Property Location & Site Information r dressMoad#: Subdivision: Phase: Lot: ordon Drive dvance NC 27006 Directions Structure: SINGLE FAMILY Hwy 158, second Redland road,-beside Andy's of-Sedmm . 3 County-Store,—tum-left-then-right-on-G-ordon-Rd-near #of People: 234 *Water Supply: PUBLIC System Specifications RKI[alS stem *Site classification: Provisionally Suitable Minimum Trench Depth: a 4 Inches Seprolite System? OYes OQ No Maximum Trench Depth: 3 6 Inches Design Flow: 3 6 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 0 - 2 7 5 1-Piece: ()Yes (j)No Pump Required: OYes ®No OMay Be Required *System Classification/Description: TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons LESS) *Proposed System: 25%REDUCTION 1-Piece: ()Yes ONo Repair System Required:@Yes ONo ONO, but has Available Space Repair System *Site Classification: Provisionally Suitable Minimum Trench Depth: 2 4 Inches Soil Application Rate: 0 - a 5 Maximum Trench Depth: 3 6 Inches *System Classification/Description: Pump Required: OYes @No ()Maybe Required TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System�25%REDUCTION Pagel of 3 PDP File Number 192206 - 1 County ID Number. *Site Modifications ❑ Open Fill Sheet 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 way guarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. Site Plan The Improvement Permit shall be valid for 6years from date of issue with a site plan(means a drawing not necessarily drawn to scale that shows the existing and proposed property lines with dimensions,the location of the facility and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters). Plat The improvement Permit shall be varid without expiration with plat(means a property surveyed prepared by a registered land surveyor,drawn to a scale of one inch equals no morethan 60 feet,that Includes:the specific location of the proposed facility andappurtenances,thesitefortheproposedWastewatersystem,andthelocationofwatersuppliesandsurfacewaters. Plat also means,for subdivision lots approved by the local planning authority and recorded with the county register of deeds,a copy of the recorded subdivisions plat that is accompanied by a site plan that is drawn to scale). The Department and Local Health Department may impose conditions on the Issuance and may revoke the permits for failure of the system to satisfy the conditions,the rules,or this article:This permit is subject to revocation If the site plan,plat,or Intended use changes(NCGS 130A-335(f)).The person owning orcontrolling the system shall be responsible forassuring compliance with the laws,rules,and permit conditions regarding system location,installation,operation,maintenance,monitioring, reporting,and repalr(.1938(b)} ApplicantlLegal Reps.Signature Required? OYes ONO Applicant/Legal Reps.Signature: Date: 'Issued By: 2140-Nations,Robert Date of Issue: 0 4 2 7 a 0 1 5 Authorized State Agent: OValid without Expiration? —� —' 0Create CA? @Hand Drawing OlmportDrawing **Site Plan/Drawing attached.** Page 2 of 3 IMPROVEMENT PERMIT • Davie County Health Department CDP File Number: 192206 - 1 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: Q Inch Drawing Drawing Type: Improvement Permit Scale' , ON jock Q a APPLICATION FOR SITE EVALUATION[RAPROVEM ENT PE & C Davie County Environmental Health Dau: 3-j ` RECEIVED P.O.Box 848/210 Hospital Street Recotved bv' Mocksville,NC 27028 DOS4Site (336)753-6780/Fax(336)753-1680 Application For: aluation/Improvement Permit ❑Authorization To Construct(ATC) ❑Both Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name Z)U g n 2 G L ona w o r t l\ Contact Person D v a o e 2 oN a w oo r`�n Address c� l 4 iv1 U,,h Fo,d DR Home Phone 33& - 39/ - 0/1 City/State/ZIP M o G lc s v,/(e A/C )7 o d 8 Business Phone Email. d do n e ,a c o.n Name on Permit/ATC if Different than Above Mailing Address ICity/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 months site plan, a iration with complete plat.) �p Owner's Name Phone Number Owner's Address a 4Lr Q W r City/State/Zip Property Address 4a f J IR A 0--e - 4 ity A ell] -VC`E'- I-V,C! Lot Size_ 1,q a C Ae TaxPRO-' Subdivision Name(if applicable) Section/Lot# Directions To Site: Specify Problem Occurring: IF RESIDENCE FILL OUT THE BOX BELOW Feople a9 Bedrooms �_ #Bathrooms a Garden Tub/Whirlpool ❑Yes 990 ement: ❑Yes BNo Basement Plumbing: ❑Yes 0No 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: C6onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: P<ounty/City Water ❑New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes Et No 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 staling the ho"acility1ocatiori, roposed well location and the location of any other amenities. operty owner's o wner's legal representative signature Site Revisit Charge Pr Date(s): Client Notification Date: Date EHS• i Sign given ❑Yes ❑No Account# q t l Revised 11106 Invoice# 4 L /�O V 4vI T a5"0If �s �S'ro tt NI 0 t �u 144A F-148 i i 3 N 1306 Ln r L� 0 6395 `' 839. 200 2396 zi D2 (245) I `—■—�' 358 so ?0 94 J 512 c• Vii.., ((( 1!45 16$5 7947 `a 458 i 0 � � e N 1 B46 r 40G 56 Aid 786 — +V 1656 to 7499 t q, s Printed:Mar 10, 2015 All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie, North Carolina,its agents,consultants,contractors or employees from any and all claims or causes of action due to or arising out of the use or Inability to use the GIS data provided by this website. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION GcarV0;;' G. Lovv wor ti Noe4f w 2�;,ti&AIP) /I s Aer'e-s &kdo,ni b(L Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L i� Slope% Z HORIZON I DEPTH -6, G Texture group e-I- 5GL Consistence er-40(tit Structure e Mineralogy HORIZON H DEPTH Texture group Consistence Structure 1/ Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE 7 m i CJtA SITE CLASSIFICATION: 617 _---- --EVALUATION BY: G'l LONG-TERM ACCEPTANCE RATE: _3-7 t) OTHER(S)PRESENT: REMARKS: 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 MQlst VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm 3Yet 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 05105(Revised) J � LA 20 v