Loading...
2336 Angell Rd z OPERATION PERMIT EEvaluated ice use UnIV ..g^'t• Davie County Health Department Number 120849-1 r� 210 Hospital Street , E30000006901 P.O. Box 848 umber. Mocksville NC 27028 r. EXISTING Phone:336-753-6780 Fax:336-753-1680 Add plicant: Frank Bledsoe rd operty Owner: Frank Bledsoe ress: 2336 Angel Road dress: 2336 Angel Road City: Mocksville City: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 Phone#: (336)306-4505 Phone#: (336)306-4505 Property Location & Site Information Address/Road #: Subdivision: Phase: Lot: 2336 Angel Road Mocksville NC 27028 Directions Structure: SINGLE FAMILY US Hwy 601 North, Right on Angel Road 1/4 mile left #of Bedrooms: on Daniel Boone Trail, lot on right. #of People: 'Water Supply: PUBLIC 'IP Issued by. 2244-Daywalt:Andrew 'System Classification/Description: TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) 'CA issued by: 2244-Daywalt,Andrew Saprolite System? O Yes O No Design Flow: 4 8 0 GRAVITY-PARALLEL(eq.d-box) Pump Required? Distribution Type: OYes QNo Soil Application Rate: 0 3 'Pre Treatment: Drain field Nitrification Field SQ 8 'System Type: INFILTRATOR QUICK 4 STANDARD No. Drain Lines Installer: saimonsseptic Total Trench Length: 1 0 0 8• Certification#: Trench Spacing: — Oinches O.C. O Feet O.C. 'EH S: 2244-Daywalt,Andrew Trench Width: Inches OFeet Date: 0 5 / 3 0 / 2 0 1 3 Aggregate Depth: inches Minimum Trench Depth: Inches Minimum Soil Cover. Inches Approval Status Maximum Trench Depth: FC03 proved O Disapproved Inches Maximum Soil Cover: Inches CDP File Number 120849- 1 Septic Tank County ID Number: E30000006901 Manufacturer. esisting Lat. Long: , STB: - - Gallons: Installer. Date: / / Certification#: *EHS: 2244-Daywalt.Andrew 'Filter Brand: ST Marker. ED Yes El No Date: Reinforced Tank: El Yes ❑ No Approval Status � Piece Tank: ❑ Yes O No El Approved❑ Disapproved Pump Tank Manufacturer. Installer: PT: Certification#: Gallons: *EHS: Date: / / Date: RiserSealed ❑ Yes ❑ No Riser Height: ❑ Yes ❑ NO (Min.6 in.) Approval Status Reinforced Tank: ❑ Yes O No ❑ Approved❑ Disapproved 1 Piece Tank: ❑ YeS ❑ NO Supply Line CPipe Size: inch diameter Installer: Pipe Length: feet Certification#: .*Schedule: 'EHS: Pressure Rated. ❑ Yes ❑ No Date: / Approved fittings O Yes ❑ No Approval Status ❑ Approved❑ Disapproved Pump Requirement Pump Type: Installer. Dosing Volume: — Gat Certification#: Draw Down: Inches 'EHS: *Chain: Dater Valves Accessible O Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ NO Check-valve ❑ Yes ❑ NO Approval Status PVC unions ❑ Yes ❑ No ❑ Approved O Disapproved Vent Hole ❑ Yes O NO Anti-siphon Hole 0 Yes ❑ NO CDP j=ile Number 120849 - 1 County ID Number: E30000006901 Electric Equipment NEMA 4X Box or Equivalent ❑ Yes ❑ NO Installer: Box 12 inches Above Grade ❑ Yes ❑ NO Certification#: Box Adj.To Pump Tank ❑ Yes ❑ NO Conduit Sealed ❑ Yes ❑ No 'EHS: Pump Manually Operable ❑ Yes ❑ NO 'Activation Method: Date: Approval Status Alarm Audible El Yes 13No ❑ Approved❑ Disapproved Alarm Visible 1:1 Yes 11No *Operation Permit completed by: 2244-Daywalt,Andrew QAuthorized State Agent: Date of Issue: 0 5 / 3 0 / 2 0 1 3 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 11 A. septic system meet the following criteria: Minimum System Review ByThe Local Health Department: NIA Management Entity: OWNER Minimum System Inspection/Maintenance FraequencyByCertified 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 entitywith 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 entitywith a certified operator forthe life of the septic system. Rule. 1961 (2)(e)requires a contract shall be executed between the system owner and a management entfty prior to the issuance of an Operation Permit fora 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. GHand Drawing Olmport Drawing **Site Plan/Drawing attached.** Total Time:(HH:MM) Activity Code: S-23B-O/P ISSUED-EXPANSION 11 0 1 Hours 0 0 bt inutes OPERATION PERMIT Davie County Health Department CDP File Number: 120849 - 1 210 Hospital Street P.O.Box 848 County File Number: E3oaoo0ossot Mocksville NC 27028 Date: Qinch OBloDravving Drawing Type: Operation Permit Scale: , ON/A = ft. QN/ _._L_ i Li i IT-1 ,U, A CONSTRUCTION For office Use only AUTHORIZATION *CDP File Number 120849-1 Davie County Health Department County ID Number. E30404006901 r' 210 Hospital Street Evaluated For: EXISTING P.O.Box 848Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone:336-753-6780 Fax:336-753-1680 0 1 / 0 1 0 0 0 6 Applicant: Frank Bledsoe r perty Owner: Frank Bledsoe Address: 2336 Angel Road dress: 2336 Angel Road City: Mocksville City: Mocksville State2ip: NC 27028 State2ip: NC 27028 Phone#: (336)3064505 Phone#: (336)3064505 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: 2336 Angel Road Mocksville NC 27028 Directions Structure: SINGLE FAMILY US Hwy 601 North, Right on Angel Road 1/4 mile left on Daniel Boone Trail, lot on right. #of Bedrooms: #of People: 'Water Supply: mm System Specifications Minimum Trench Depth: .2 4 Site Classification: PS 71nches Minimum Soil Cover. (Seprolite System? OYes ONo Design Flow: 4 $ 0 Maximum Trench Depth: 36 nces Soil Application Rate: 0 . 3 Maximum Soil Cover: Inches 'System Class ification/Description: 'Distribution Type: GRAVITY-PARALLEL(eq.d-box) TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: Gallons 'Proposed System: 25%REDUCTION 1-Piece: OYes ONo Pump Required: OYes ONo OMay Be Required Nitrification Field Sq. ft. Pump Tank: Gallons No. Drain Lines 1-Piece: OYes ONo Total Trench Length: 1 0 0 ft GPM—vs— ft. TDH Trench Spacing: — OInches O.C. — OFeet O.C. Dosing Volume: Gallons Trench Width: Inches SFeet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-II Septic Tank Installer Grade Level Required: 01 OI I 0111 O IV Page 1 of 3 CDP File Number 120849- 1 County ID Number. E30000006901 ❑ Open Pump System Sheet Repair System Required:OYes ONO ONo, but has Available Space rDesign System Trench Spacing: Q Inches 0. . ification: Ps — 9 Feet O.C. Trench Width: D Inches w: 4 8 0 - 3 6 Feet Soil Application Rate: Aggregate Depth: 0 3 inches Minimum Trench Depth: a 4 Inches =System Classification/Description: TYPE Ilk CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. Inches *Proposed System: a Maximum Trench Depth: 3 6 25/o REDUCTION Inches Maximum Soil Cover: Nitrification Field Sq. Inches ft. No. Drain Lines "Distribution Type: GRAVITY-SERIAL Total Trench Length: 4 0 0 ft Pump Required: QYes ONo OMay Be Required Pre Treatment: ONSF OTS-1 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 of this permit bythe Health Department in no wayguarantees the issuance of other permits.The permit holder is responsible for checking with appropriate goveming bodies in meeting their requirements. This Authorization for Wastewater 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 issued atthe same time 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 the application fora permit or Construction Authorization Is found to have been Incorrect falsified or changed,or the site Is altered,the permit or Construction Authorization shall become Invalid,and may be suspended or revoker!(.1937(g)).The person awning or controlling the system shall be responsible for assuring compliance With the laws,noes,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: *Issued By: 2244-Daywalt.Andrew Date of Issue: 0 4 / 0 8 / a 0 1 3 Authorized State Agent: Malfunction Log Oyes AA I tAi �XayQff E)Handibrawing Olmport Drawing Total Tirne:(H KM M) **Site Plan/Drawing attached.** 1 Hours_ Minutes Page 2 of 3 S-9-CIA ISSUED-EXPANSION CONSTRUCTION AUTHORIZATION 120849- 1 • Davie county Health Department CDP File Number: 210 Hospital Street E30000006901 P.O.sox 848 County File Number. Mocksville NC 27028 Date: 0 4 / 0 8 / 2 0 1 3 Q Inch Drawing Drawing Type: Construction Authorization Scale: . Oft. QN/A L-5L-_I I L j I 1a-.l_ Li �_ .___9_ __l-.►____�___�___ � P a, 3tI'� I i I I I HEALTH DEPARTMENT RELEASE F2LQ1"e use OnN i '• *CDP File Number 120849-1 Davie County Health Department E30000006901 210 Hospital Street County ID Number: P.O. Box 848 EXISTING -- Evaluated For: Mocksville NC 27028 Phone:336453-6780 Fax:336-753-1680 PERMIT VALID 0 4 / 0 4 / 2 0 1 8 UNTIL: Applicant: Frank Bledsoe Property Owner: Frank Bledsoe Address: 2336 Angel Road Address: 2336 Angel Road City: Mocksville City: Mocksville State2ip: NC 27028 State2ip: NC 27028 Phone#: (336)306-4505 Phone#: (336)306-4505 Property Location&Site Information Address2336 Angel Road Subdivision: Phase: Lot Road# Mocksville NC 27028 SINGLE FAMILY Township: *Structure: Directions #of Bedrooms: #of People: US Hwy 601 North,Right on Angel Road 1/4 mile left on Daniel Boone Trail,lot on right. *Water Supply: WA Type of Business: Basement: 0 Yes�No Total sq.Footage: No.Of Employees: *Proposed Improvement: Release Conditions It is the responsibility of the owner to maintain a 5'minimum setback between the wastewater system and any part of the structure foundation,including porches,decks,and any other appurtenances. If you are unsure as to the exact location of the septic system,please have a licensed installer or Inspector locate the septic system for you. The local county health department in no way implies that the proposed construction meets the required setbacks from the septic system unless otherwise noted. This release only shows that this property has an approved wastewater system that appears to have met the permitting requirements at the time it was installed. This release in no wayexpresses or implies that the existing subsurface sewage treatment and disposal system serving the sie will continue to function for any period of time. Applicant/Legal Reps.Signature Required? OYes GNo Applicant/Legal Reps.Signature, *Date: *Issued By: 2244-Daywalt,Andrew *Date of Issue: 0 4 / 0 3 / 2 0 1 3 Authorized State Agent: **Site P Ian/D wing attached.** Total Tlme:(HH:MM) r 0 1 Hours Minutes 01-land Drawing Olmport Drawing IMPROVEMENT PERMIT ForOffceUse only rDPFileNumber 120849- 1 Davie County Health Department E30000006901 210 Hospital Streetunty ID Number. '� .. . P.O. Box 848 Evaluated For: EXISTING Mocksville NC 27028 Township: Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID UNTIL 4!512018 "NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: Frank Bledsoe Property owner. Frank Bledsoe Address: 2336 Angel Road Address: 2336 Angel Road City: Mocksville Cly: Mocksville State2ip: NC 27028 State2ip: NC 27028 Phone#: (336)306-4505 Phone#: (336)306-4505 Proert Location & Site Information Address/Road#: Subdivision: Phase: Lot: 2336 Angel Road Mocksville NC 27028 Directions Structure: SINGLE FAMILY US Hwy 601 North, Right on Angel Road 1/4 mile left #of Bedrooms: on Daniel Boone Trail, lot on right. #of People: 'Water Supply: NIA System Specifications rited—Classincation: ial System Minimum Trench Depth: 2 4 Inches e System? OYes GNo Maximum Trench Depth: 3 6 Inches Design Flow: 4 8 0 Septic Tank: Gallons Soil Application Rate: 0 . 3 1-Piece: OYes QNo Pump Required: OYes GNo OMay Be Required *System Classification/Description: TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons LESS) 'Proposed System: 25%REDUCTION 1-Piece: OYes ONo Repair System Required:0 Yes ONO ONO, but has Available Space cSoiiReaair System ti e Classification: PS Minimum Trench Depth: 2 4 Inches Application Rate: 0 - 3 Maximum Trench Depth: 3 6 Inches 'System Classification/Description: Pump Required: OYes (E)No O Maybe Required TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) -.Proposed System: 25%REDUCTION Page 1 of 3 CDP File Number 120849- 1 County ID Number. E30000006901 '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 by the 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. Site Plan The Improvement Permit shall be wild for 5 years from dateof Issue with a site pan(means a drawing not necessarily drawn to scale that shows the existing and proposed property Imes with dimensions,the location of thefacility and appurtenances,the O "` site forthe proposed Wastewater system,and the location of water supplies and surface waters). Plat The Improvement Permit shall be wild without expiration with plat(means a property surveyed prepared by a registered land surveyor,drawn to a scale of one Inch equals no more than 60 feet,that Includes:the specific location of the proposed facility O and appurtenances,the site for the proposed Wastewater system.and the location of water supplies and surface waters. 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,plate or Intended use changes(NCOS 130A-335(1)).The person owning or controlling the system shall be responsible for assuring compliance with the laws,sties,and permit conditions regarding system location.Installation,operation,malntenance,monitoring, reporting,and repair(.1938(b)} Applicant/Legal Reps.Signature Required? Oyes QNO Applicant/Legal Reps. Signature; Date: *Issued By: 2244-Daywalt,Andrew Date of Issue: 0 4 0 5 2 0 1 3 Authorized State Agent: OValid without Expiration? O Create CA? @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Total Time:(HI—IJA d) 0 1 Hours. LI inutes Page 2 of 3 Activitv Code: S-5-IPS issued:expansion of existing system IMPROVEMENT PERMIT 120849- 1 Davie County Health Department CDP File Number. 210 Hospital Street P.O.Box 848 County File Number: E30000006901 Mocksville NC 27028 Date: Q Inch Drawing Drawing Type: Improvement Permit Scale: QBlock ON/A --l— J-1--.1--L-1 J.— i ;I it X(60, ' '0i ! 1 ! Page 3 of 3 Davie County,NC- GoMaps Advanced Page 1 of 1 Davie - ILL] 3437 ►r ti f, `3`134 3427 • i` 2294 '°► E : X3413 i N r 4 ! y VI 'l-'12344 ., 3401 1, I E 131 o r j E k rf I n 2340 +a' t .a ! � � E+ �a ..� � r� 2292 I 122 Ej X233 r -; 2404 2286 2355 • `?ems,.. _ _2442I1 ( � tiIT i 1 loom f `2429 ++ t 500 ft Latitude; 350 8'51.73' Longitude: -800 37'15.81' + • 1,' jj I 7 http://maps2.roktech.net/davie_gomaps/index.html 4/5/2013 Davie County Health Department 6f Environmental Health Section o P.O. Box 848 EGEOV 210 Hospital Street 0& Courier# : 09-40-06 f'1AR 2 1 2013 Mocksville,NC 27028 Phone:(336)-753-6780 BY: _____� ax:(336)-753-1680 ON-SITE WASTEWATER CERTIFICATION ,(Check One) Replacement Remodeling Reconnection Name:tsm',K—fit c_A S 0 e Phone Number 33� 50(o (Home) Mailing Address: Ce '/& y7 (Work) (cloaks,4 Al c- z?al a Detailed Directions To Site: Ito) Mf`l'l, \IBJ A w iizo `l4' Property Address: Z33Ct J P44 f ,-7,q,0 Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under:��', l t,4 so-C Type Of Facility: I L\j M 14 ontc: 7 Date System Installed(Month/Date/Year): �`L'G7S Number Of Bedrooms: __^ Number Of People:_ Is The Facility Currently Vacant? Yes No If Yes,For How Long? - nw� AN t'j Any Known Problems? Yes No If Yes,Explain: Please Fill In The Followiug Information,About The NEW Facility: Type Of Facility: 3Z10G 0�1dd Number Of Bedrooms:�_Number of People Pool Size: Garage Size: Other: RequestedBy: . Gam" a Date Requested: 3'20- /3 (Signature) For Environmental Health Office Use Only Approved Disapproved Comments: Environmental Health Specialist Date: *The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee (extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cas Chec oney Order # Amount:.$ ate: Z Paid By: . j Y� Received By: Account#: 1 #: y 5`3a1I sob r�' Dui 4 Y ,3 �2 t x i 1 O)to ?(a0 _ _ _. . .__.. -- --- - - / tam _ ._. . - __......_. ...._ -._ ---- __.._ ___ --------- -... by ` I I j � I II f I � i 23( DAVIE COUNTY HEALTH DEPARTMENT ; IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION `NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a Sanitary.e is Sewage Systems W Permit Number Name.4, -2r 1L� �L Dai 2'•� _�f N2 8127 �/J1v7r�,1P Location — — Subdivision Name Lot No. Sec. or Block No. Lot Size -- — House —Mobile Home --__ Business Industry No. Bedrooms _.No.'Baths - No. in Family Public Assembly Other Garbage Disposal YES 0 NO 0 Specifications for System: Auto Dish Washer YES 0 NO 0 Auto Wash Ma^hine YES 0 NO 0 Type Water Supply --- -- --- 'This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE)NSTAW,NG.,THIS SYSTEM. oe ,%�' {i` !2 `/-i, c }.-�`c� ,i'( -iE'��✓?i pre- Improvements reImprovements permit by 'Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M., 1:00-1:30 P.M.or 4:30-5:00 P.M.on day of completion.Telephone Number:704-63458 Mo Final Installation Diagram: System Installed by oja Certificate of Completion _ Date �� / _ 'The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for'any given period of time. 01 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CER*JF,,ICATE'OF COMPLETION *NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a " Sanitary Sewage Systems Permit Number Name �Ln :r? ✓C -?Y,, Dae N2 8 1 Location Subdivision Name Lot No. Sec. or Block No. Lot Size -- — House —Mobile Home ---_ Business -- Industry No. Bedrooms —.No. Baths --2--No. in Family Public Assembly Other Garbage Disposal YES ❑ NO ❑ Specifications for System: Auto Dish Washer YES ❑ NO ❑ Auto Wash Ma^hine YES ❑ NO ❑ ����� ��� / Type Water Supply ,— -----*This permit permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALIJNP THIS SYSTEM. ;. r y_ .r- r� . Improvements permit by — r *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M., 1:00-1:30 P.M.or 4:30-5:00 P.M.on day of completion.Telephone Number: 704-6344M.W6d Final Installation Diagram: System Installed by D� � Certificate of Completion' –_&-6zez1 _.Date --- 'The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation;but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. t✓ DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) NAME /'//."��/G c� �i.�)rl'�i£A�IS PHONE NUMBER ADDRESS ? SUBDIVISION NAME LOT# DIRECTIONS TO SITE DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY e NUMBER BEDROOMS . SP NUMBER PEOPLE SERVED TYPE WATER SUPPLY 4/1 SPECIFY PROBLEM OCCURRING DATE REQUESTED INFORMATION TAKEN BY CPQ This is to certify that the information provided is correct to the best of my knowledge,and that I understand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT i Rev.1/93