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1512 Baltimore Rd
OPERATION PERMITor or ice use, nv Davie County Health Department *CDP File Number 191982-1 R. 210 Hospital Street P.O.Box 848 County Number. `=•� Mocksville NC 27028 Evaluated For. NEW Phone:336-753-6780 Fax:336-753-1680 Township: Applicant: Richard Robertson Property Owner: Richard Robertson Address: 2135 Comatzer Road Address: 2135 Comatzer Road City: Advance City: Advance Statefzip: NC 27006 State2ip: NC 27006 Phone#: (336)998-4755 Phone#: (336)998-4755 Property Location & site Information r dress/Road#: G I'j� Subdivision: Phase: Lot: Baltimore Road J vance NC 27006 Directions Structure: SINGLE FAMILY hwy,158 East to Baltimore Rd on right just before the end between Princeton Court and the Yadkin Valley of-Bedrooms: _ 0 Telephone Building. #of People: *Water Supply: PUBLIC *IP Issued by. 2140-Nat�s,Robed 'System Class ification/Description: TYPE II A COW SYSTEM(SINGLE-FAMILY OR 4$0 GPD OR LESS) *CA issued by: 2140-Nations,Robed SaproliteSystem? QYes QNo Design Flow: 3 6 0 *Distribution Type: GRAVITY-PARALLEL(eq.d•boz) Pump Required? QYes QNo Soil Application Rate: 0 3 *Pre Treatment: Drain field (No. itrification Field 1 2 0 0 Sq.ft. *System Type: INFILTRATOR QUICK a STANDARD Drain Lines 3 Installer: Jamie Barnes Total Trench Length: 3 0 0 ft. Certification#: tots Trench Spacing: 9 Inches O.C. — Feet O.C. *EH S. 2140-Nations,Robert Trench Width: 3Inches gFeet Date: 0 6 / 1 0 / 2 0 1 6 Aggregate Depth: inches Minimum Trench Depth: 3 5 Inches Minimum Soil Cover. 4 ApprovalyStatus Inches , Maximum Trench Depth: 3 6 Inches ;® .Approved O Disapproved: Maximum Soil Cover: a 4 Inches CDP Fite Number 191982 ` 1 County ID Number: Septic Tank ' Manufacturer. Shoaf Let. STB. 760 Long: Gallons: 1000 InstallerJamie Games Certification#: 1018 Date: 0 3 / 1 8 / .1 0 1 6 *EHS: 2140-Nations.Robert *Filter Brand: POLYLOK PL-122 With Pipe Adapter ST Marker. 11 Yes CJ NO Date: 0 6 / 1 0 / 2 0 1 6 Reinforced Tank: ❑ Yes 501 No Approval Status Piece Tank: ❑ Yes ® No D Approved❑ �Dtsapproved Pump Tank ("Manufacturer Installer PT: Certification#: -Gallons: ! *EHS: Date: ' / Date: Riser seated ❑ Yes ❑ No Riserlieght: ❑ Yes - '❑ No (Min.6 in.) Approval Status einforced Tank: ❑ Yes ed❑ No ❑ Approv ❑ Dtsapprovetl 1 Piece Tank; ❑ Yes ❑ No Supply Line Pipe Size; inch diameter Installer. Pipe Length: feet Certification#: *Schedule: *EHS: Pressure Rated ❑ Yes ❑ No Date: Approved fittings [I Yes ❑ No ApprovalStetus ❑ Approved❑ Dlsa0Drovetl 3ta- Pump Requirement Pump Type: Installer. Dosing Volume: - Gal Certification#: Draw Down: Inches *EHS: *Chan: Date: Valves Accessible ❑ Yes ❑ NO Flow Adjustment Valve ❑ Yes ❑ NO Check-valve ❑ Yes ❑ NoApproval=status PVC unions El Yes El No ❑,Approved Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ Yes ❑ NO CDP File Number 191982 - 1 County ID Number: 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 *EH S: Pump Manually Operable ❑ Yes ❑ No *Activation Method: Date: Approval Stafus Alarm Audible ❑ Yes E3No Q Approvetl❑ 131sapprove Alarm Visible ❑ Yes ❑ No 2140-NaGons.Robert *Operation Permit completed by: Authorized State Age ._ Date of Issue: 0 6 / 1 0 / 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 IIk sewage septic system. Rule.1961 requires that a Type TYPE 11 A. septic system meet the following criteria: Minimum System Review By The Local Health Department: NIA Management Entity: OWNER - Minimum System InspectioniMaintenance FrequencyByCertified 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 avalid contract with a public management entity with a certified operator or a private certified operator for the life of the septic system. Rule.1961 requires that Type VI septic systems designed for a 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 entity 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 Olmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT 191982- 1 Davie County Health Department C,DP File Number: 210 Hospital Street P.O.Box W County File Number: Mocksville NC 27028 Date: Olnch Drawing Drawing Type: Operation Permit Scale: OON A k 6 -� G�► I I ` Ll r CONSTRUCTION For office use 0niy AUTHORIZATION "CDP Fife Number 191982-1 N Davie County Health Department County ID Number: 21.0 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 7 / a 4 / a 0 a 0 Applicant: Richard Robertson Property Owner: Richard Robertson Address: 2135 Comatzer Road Address: 2135 Comatzer Road City: Advance City: Advance State/Zip: NC 27006 State/Zip: NC 27006 Phone#: (336)998-4755 Phone#: (336)998-4755 Property Location R Site Information r ress/Road#: Subdivision: Phase: Lot: altimore Road dvance NC 27006 Directions Structure: SINGLE FAMILY hwy 158 East to Baltimore Rd on right just before the end between Princeton Court and the Yadkin Valley #of Bedrooms: 0 Telephone Building. #of People: "Water Supply: PUBLIC System Specifications Minimum Trench Depth: a 4 Site Classification: Provisionally Suitable Inches Minimum Soil Cover. Saprolite System? OYes ®No 1 a Inches Design Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 - 3 Maximum Soil Cover: a 4 Inches "System Classification/Description: "Distribution Type: GRAVITY-PARALLEL(eq.d-box) TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons *Proposed System: 25%REDUCTION 1-Piece: Oyes @No Pump Required: OYes @No OMay Be Required Nitrification Field 1 a 0 0 Sq. g. Pump Tank: Gallons No.Drain Lines 3 1-Piece:OYes ONo Total Trench Length: 3 0 0 ftGPM vs— ft. TDH Trench Spacing: Inches O.C. 9 . @Feet O.C. Dosing Volume: _ Gallons Trench Width: _ Q Inches 3 ©Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-11 Septic Tank Installer Grade Level Required: 01 011 0111 OIV Dan&1 nf'A CDP File Number 191982 - 1 County ID Number. ' ❑ Open Pump System Sheet Repair System Required:®Yes ONo ONo, but has Available Space eaair System Trench Spacing: Q Inches 0. . *Site Classification: Provisionally Suitable — 9 # Feet O.C. Trench Width: Inches Design Flow: 3 6 — 3 Feet Soil Application Rate: 0 - a 7 5 Aggregate Depth: 1 inches Minimum Trench Depth: a 4 '°System Classification/Description: Inches TYPE 11 A.CONV SYSTEM(SINGLE-FAMILY OR ODGPD OR LESS) Minimum Soil Cover. :1 a Inches "Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: a 4 Nitrification Field 1 a 0 0 Inches Sq.ft. No. Drain Lines 3 *Distribution Type: .GRAVITY-PARALLEL(eq.d-box) Total Trench Length: 3 � � g. Pump Required: �Yss �No 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 by the 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. A I This Authorization for Wastewater system Constriction shall be valid for a person equal to the period of validity of the Improvement Permit,not. to exceed five years,and may be issued at the 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 orConstruction Authorization shall become Invalid,and may be suspended or revoked(.1937(8)).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,monitoring,reporting and repair Applicant/Legal Reps.Signature Required? OYes ONo Applicant/Legal Reps.Signature: Date.- 2140-Nations,Robert Issued By: 0 7 a 4 a 0 1 5 Date of Issue:..._._. Authorized State Agent: Malfunction Log OYes @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 s CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File'Number: 191982- 1 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: 0 7 / a 4 / a 0 1 5 Q Inch Drawing Drawing Type: Construction Authorization Scale: . QBlock = ft• QNIA �C d T,t,�r � i e r-R 00 7 a — I I 3 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number. 191982 " 1 P.O.Box 848 Mocksville NC 27028 County File Number: 6 0 G S' Q Al (Q u Date: 07 / 24 / 2015 Click below to import an Image irorri an external location: Drawing Type:Construction Authorization vV �o u 1 � �V6� IMPROVEMENT PERMIT Fbr,officeuse.only CDP File Number 191982;- 1 Davie County Health Department � � �. ,County ID tJ,umber: 210 Hospital Street P.C. Box 848 Evaluated For NEW • Mocksville NC 27028 Township:' Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID UNTIL 4/27/2020 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this ImprovementPennit. Applicant: Richard Robertson Property owner. Richard Robertson Address: 2135 Cornatzer Road Address: 2135 Comatzer Road CRY: Advance City: Advance StatefZip: NC 27006 State/Zip: NC 27006 Phone#: (336}9J8-4755 Phone#: (336)998-4765 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: Baltimore Road Advance NC 27006 Directions Structure: SINGLE FAMILY hwy 158 East to Baltimore Rd on right just before the "f-Bedrooms— etween-P-rinceton-GOurt_andAl e-Yadkin-Y-alley – #of People: Telephone Building. *Water Supply: PUBLIC r13Pffi—lt— S stem S ecifications ial S s�tem assl icetion:Provisionally SuitableMinimum Trench Depth: a 4 Inches rolite System? OYes i�)No Maximum Trench Depth: 3 6 Inches Design Flow: 3 6 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 0 - 3 1-Piece: OYes *No Pump Required: OYes QNo 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-Pt@Ce: OYeS ONO Repair System Required:*Yes ONo ONO, but has Available Space Repair System `Site Classification: Provisionallysuttabte Minimum Trench Depth: a 4 Inches Soil Application Rate: 0 - a 5 Maximum Trench Depth: 3 6 Inches *System Classification/Description: Pump Required: OYes *No O Maybe Required TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System: 25%REDUCTION Pagel of 3 CDP File Number 191982 - 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 me Improvement Permit shall be valid for 6 years from date of Issue with a site plan(means a drawing not necessarily drawn to scale that shows the existing find proposed property lines with dimensions,the location ofthefaciltty and appurtenances,the sitefortheproposedwastewatersystem,andthelocationofwatersuppliesandsurfacewaters). Plat The Improvement Permit shall be valid without expiration with plat(means a property surveyed prepared by aregistered land surveyor,drawn to a scale of one inch equals no morethan fit)feet,that Includes:the spedfic location ofthe proposed facility O and appurtenances,the site for the proposed Wastewater system.and the location of water supplies and surfacewaters. 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 penult is subject to revocation if the site plan,plan or Intended use changes(NCGS 1304 335(0).The person owning or controlling the system shall be responsible for assuring compliance with the laws,rides,and permit conditions regarding system location,installation,operation,maintenance,monitoring, reporting,and repair(1938(b)l ApplicantlLegal Reps.Signature Required? OYes ONO Applicant/Legal Reps.Signature: Date: "Issued By: 2140-Nations,Robert Date of Issue: 0 4 a 7 a 0 1 5 : r --i-�--� OValid without Expiration? Authorized State A g—fOCreate CA? *Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 IMPROVEMENT PERMIT 1 ,1982 _ � Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: Q Inch Type: Improvement Permit Seale: QBlock Drawing Drawin g YP p N!A -JsFo J Id'sId's ---1 - i — T- J -' APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 tau: (336)753-6780/Fax(336)753-1680 _!db ' Applicatio Site valuation/Improvement Permit ❑ Authorization To Construct(ATC) ❑Both Type of Application: Kew 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 9 TD h er C,.A Contact Person Address W. Home Phone ?36 RRT 14'7 5-5- City/State/ZIP y- City/State/ZIP Rd v t t c_e A2C, -1-706(, Business Phone Email Name on Permit/ATC if Different than Above Mailing Address City/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 with site plan,no expiration with complete plat.) Owner's Name—Ec-L ,d Phone Number 5-3— Owner's Address_2-1 35' C•n r n e 1-z_e-r �City/State/Zip � �c�Ge /1�e, 7,-x� PropertyAddress l "�iM p y-� Rrk. City /ted J acti - , - Lot Size Tax PIN# Subdivision Name(if ap licable) Sec 'o ot# ISire do s To Site: 5- o G Sp ci r b em Occurring: IF RESIDENCE FILL OUT THE BOX BELOW #People I— #Bedrooms '3 #Bathrooms 2 Garden Tub/Whirlpool ❑Yes UK6 Basement: Cr}Yes ❑No Basement Plumbing: ❑Yes ❑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: ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: R"County/City Water ❑New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 9 N'o 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 corners and locating and flagging 7=g the %�Ilitv t�� ell location and the location of any other amenities. Site Revisit Charge , Property owner's or owner's legal representative signature Date(s): Client Notification Date: Date EHS: i Sign given ❑Yes ❑No M�d Account# ` 1 Revised 11/06 Invoice# ,1 1 L p v a° ` l,r(Vvu GZ--c --�� 1 J `• DAVIE COUNTY HEALTH DEPARTMENT r Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Richard Robertson Baltimore Road 336 998-4755 Acreage 7- 1 Water Supply: On-Site Well Community Public Evaluation By: Auger Boring / Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position 1_ Slope% HORIZON I DEPTH Texture group C_ G 5 Consistence 1 P Z, - Structure S F Mineralogy / HORIZON H DEPTH Texture groupc Consistence Pt Structure L SB '5 6�; Mineralogy L 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 0' .7 F SITE CLASSIFICATION: T--- EVALUATION BY: LONG-TERM ACCEPTANCE RATE: 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 CONSIST .N mdq VFR-Very friable FR-Friable FI-Firm . VFI Very firm EFI-Extremely firm 3�t 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 Nato 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)