1077 Angell Rd • CONSTRUCTION For office Use Only
AUTHORIZATION xcDP File Number 137347- 1
°= Davie County Health Department County ID Number: F4-000-00-05i
I 210 Hospital Street Evaluated For: REPAIR
'•, �,.r P.O. Box 848 Townshi
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Mocksville NC 27028 PERMIT VALID UNTIL.-
Phone:
NTIL:Phone:336-753-6780 Fax: 336-753-1680 0 4 / 1 1 a 0 1 9
Applicant: Keith Siler r
ty Owner: Keith Siler
Address: 1077 Angell Road s: 1077 Angell Road
City: Mocksville y: Mocksville
State2ip: NC 27028 State/Zip: NC 27028
Phone#: Phone#:
Property Location & Site Information
Address/Road M Subdivision: Phase: Lot:
1077 angel)Road
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 158, left on Main Ch Rd. Right on Cana, Right on
Angell on right
#of Bedrooms:
#of People:
"Water Supply: N/A
System Specifications
Minimum Trench Depth: D 4
Site Classification: Provisionally Suitable Inches
Minimum Soil Cover.
Saprolite System? QYesNo 1 a Inches
Design Flow: a .� 5 Maximum Trench Depth: 3 6 inches
Soil Application Rate: Maximum Soil Cover: 4
a 4 0 Inches
'System Classification/Description: 'Distribution Type: GRAVITY-SERIAL
TYPE it A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
Gallons
'Proposed System: 25%REDUCTION 1-Piece: O Yes O N o
Pump Required QYes ONo OMay Be Required
Nitrification Field 8 7 3 Sq. ft. Pump Tank: Gallons
No. Drain Lines a 1-Piece: QYes QNo
Total Trench Length: a 1 8 GPlyl—vs-- ft. TDH
Trench Spacing: Inches O.C.
9 . gFeet O.C. Dosing Volume: _ Gallons
Trench Width: Inches
3Feet Grease Trap: Gallons J
Aggregate Depth: inches
Pre-Treatment: ONSF OTS-1 OTS-II
Septic Tank Installer G rade Level Required. 01 0I1 0111 01V
CDP File Number 1:37347- 1 County ID Number: F4-000-00-051
❑ Open Pump System She(
Repair System Required:OYes ONo ONo, but has Available Space
e;air system
Trench Spacing: V Inches 0.C_
*Site Classification: Feet O.C.
Trench Width: Q Inches
Design Flow: — o Feet
Aggregate Depth:
Soil Application Rate: inches
'� • Minimum Trench Depth:
*System Classification/Description: Inches
Minimum Soil Cover.
Inches
*Proposed System: Maximum Trench Depth: Inches
Maximum Soil Cover:
Nitrification Field Inches
Sq. ft.
:. "Distribution Type:
No. Drain Lines
Total Trench Length: ft Pump Required: OYes ONo OMay Be Required
Pre Treatm$nt: O N.SF OTS-I OTS-11
*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 ofthis perm1 bythe Health Department in no wayguarentees the issuance of other permits.The permit holder
Js responsible for checking with appropriate goveming bodies in meeting their requirements.
Minis Authorization for Wastewater System Construction.shall be valid for a pemon.equal to the period of validity of the improvement Pemnit,not
to exceed five years,and maybe Issued at the same time the improvement Permit Issued(NCGS 130A-336(b)).If the tnstailation has not been
completed during the period of validity of the Construction Permit,the information submitted in the application for a permit or Construction
Authorization is found to have been incorrect falsified or changer!,or the site is altered,the permit or Construction Authorization shall become
Invalid.and may besuspended or revoked(,1537(g)).The person owning orcontrolling the system shall be responsible for assuring compliance
With the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance,monitoring,reporting and repair
Appi ica nt/Le gal Reps.Signature Required? Oyes ONo
Applicant/tegai Reps. Signature Date: - /
*issued BY 2140•:Nations,Robert Date of Issue: 0 4 / 1 1 / a 0 1 4
Authorized State Agent: :w 'n, Malfunction Log Oyes
VMand Drawing Olmport Drawing
CONSTRUCTION AUTHORIZATION
Davie County Health Department CDP File Number: 137347 - I
210 Hospital Street F4-000.00-051
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 0 4 / 1 1 / .1 0 1 4
Q Inch
Drawing Drawing Type: Construction Authorization Scale: . QBlock =
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- DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
REPAIR IMPROVEMENT PERMIT
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account : 990006175 Tax PIN!EH M 174-000-00-051
t
Billed To: Keith Siler Subdivision Info:
Reference Blame: REPAIR PERMIT LocalioniAddress: 1077 Angell Rd.-27028
Proposed Facility: Residential Repair Property Size: 10.250 AC
ATC Number 6065 Site Type: ❑New IgRepair ❑Expansion
**NOTE**This IP/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 IP/AUTHORIZATION TO
p 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: #Bedrdoms_ #Bathrooms #People Basement❑Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
CA- f
Lot Size 10 .1 Type of Water Supply: County/City ❑Well ❑Community Well
.5-c,�q
System Specifications: Design Wastewater Flow(GPD)'14 Tank Size X' GAL./Pump Tank GAL.
h Trench Width 3 G Max.Trench Depth 3 Rock Depth__?L Linear Ft.
t Z Site Modifications/Conditions/Other:
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)753-6780.
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r .Environmental Health Specialist Date:
I, DCHD 11/06(Revised)
t DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
" Mocksville, NC 27028
(336)753.-6780/Fax# (336)753-1680
REPAIR OPERATION PERMIT .
M Account #: 990006175 Tax PIN/EH#: 174-000-00-051
Billed To: Keith Siler Subdivision Info:
2 Reference Name: REPAIR PERMIT Location/Address: 1077 Angell Rd.-27028
1 Proposed Facility: Residential Repair Property Size: 10.250 AC
ATC Number: 6065
**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 betaken as a guarantee that the system will function satisfactorily for any given period of
1 time.
System Type: S.T.Manufacturer Tank Date Tank Size
Pump Tank Size Bedrooms -
System Installed By: Installer#: Date:
GPS Coordinate:
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ti Environmental Health Specialist: Date:
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€ DCHD 11/06(Revised)