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738 Baltimore Rd
OPERATION PERMIT F"*CDP ice use ny Davie County Health Department Number 199254-210 Hospital Street 5861-80-0318N P.O. Box 848 umber, =' Mocksville NC 27028 Evaluated For NEW" Phone:336-753-6780 Fax:336-753-1680 Township: , Applicant: Jerry W. Grubbs Property Owner. Patricia Chaffin Grubbs Address: 107 Inland Court Address: 107 Inland Court City: Kemersville City: Kemersville State2ip: NC 27284 Statefzip: NC 27284 Phone#: (336)784-4668 Phone#: (336)784-4668 Property Location & Site Information r dress/Road#:*- �� Subdivision: Phase: Lot: Baltimore Road Advance NC 27006 Directions Structure: SINGLE FAMILY Hwy 158 East right on Baltimore Road second property on right past Juney Beauchamp Rd #of Bedrooms: 2 #of People: *Water Supply: EXISTING WELL *IP Issued by. 2140•Nations,Robert *System Class ification/Description: TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140.Nations,Robert SeproliteSystem? QYes ONo Design Flow: 2 4 0Distribution Type: GRAVITY-SERIAL Pump Required? QYes IDNo Soil Application Rate: 0 - a 'Pre Treatment: Drain field (Nitrification Field 1 2 0 0 Sq•ft• *System Type: INFILTRATOR QUICK 4 STANDARD o. Drain Lines 3 Installer: Randy Miller Total Trench Length: 3 0 0 ft. Certification#: '1128 Trench Spacing: — 9 Inches O.C. Feet O.C. *EH S: 2140-Nations.Robert Trench Width: 3 Inches gFeet Date: 0 3 / 0 2 / 2 0 1 6 Aggregate Depth: inches Minimum Trench Depth: 3 6 . Inches Minimum Soil Cover. 4 Inches Approval Status Maximum Trench Depth: 3 6 ® Approved O Disapproved Inches t� Maximum Soil Cover. 4 Inches COP File Number 1992,54 , 1 Septic Tank County ID Number: 5861-80-0318 Ma7nufacluer Lat. Long: aons: Installer Date: I / Certification#: ` *EHS: *Filter Brand: ST Marker: ❑ Yes ❑ No Date: Reinforced Tank: E] Yes ❑ No , Approval Status Piece Tank: D Yes ❑ No ❑ Approved❑ Disapproved Pump Tank Manufacturer. Installer. PT: Certification#: Gallons: *EHS: Date: Date: _ RiserSealed ❑ Yes ❑ No RiserHeght: ❑ Yes ❑ No (Min.6 in.) Approval Status �IlPicce ored Tank: ❑ Yes ❑ Nop Approved❑"DisapprovedTank: ❑ Yes ❑ No Supply Line FPoe ize: inch diameter Installer. gth: feetCertificationcedule: THS: Pressure Rated ❑ Yes ❑ No Date: Approved fittings ❑ Yes ❑ No Appfoval Status ❑ Approved❑ ©IsapprOved' Pump Requirement Pump Type: Installer. Dosing Volume: — Gal Certification#: Draw Down: Inches THS: *Chain: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ N0 Check-valve ❑ Yes ElNo .�ApprovalStatus PVC unions El Yes O No ❑ Approved ElDisapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ Yes 0 No CDP File.Number 199254 - 1 County ID Number: 5801.80-0318 Electric Equipment NEMA 4X Box or Equivalent Q Yes ❑ No Installer: Box 12 inches Above Grade ❑ Yes ❑ No Certification#: Box Adj. Pump Tank ❑ Yes ❑ NO Conduit Sealed ❑ Yes ❑ No 'EHS: Pump Manually Operable ❑ Yes ❑ No / *Activation Method: Date: Approval Status Alarm Audible C3 Yes ❑ No , ❑ ,Approved❑ Disapproved Alarm Visible ❑ Yes ❑ No 2140-Nations,Robert 'Operation Permit completed by: Authorized State Agent: Date of Issue: 0 3 / 0 2 / 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 11 A sewage septic system. Rule .1961 requires that a Type TYPE If A. septic system meet the following criteria: Minimum System Review By The Local Health Department: N/A Management Entity: OWNER Minimum System InspectioniM aintenance Frequency By Certified Operator: NIA Reporting Frequency By Certified Operator.WA Rule.1961 requires that a Type IV and V septic systems designed fora homelbusiness 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 for a 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 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 ownerand certified operator are the same. The contract shall require specific requirements formaintenance 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 199254 - 1 Davie County Health Department CDP File Number: 210 Hospital Street 5861-80-0318 P.O.Box 848 County File Number: Mocksville NC 27028 Date: ! 1 Olnch Drawing yawing Type: Operation Permit Scale: . O = ft. ON/A I , V � e �( l 2- O�. k r � � r �Qc�l• � f�C � 6 � L � 1 s � Date Attendees Topic Meeting Objectives Notes t v a 1 Action Items !fin c✓ ❑ CONSTRUCTIONFor office Use Only, x'. AUTHORIZATION *CDPkle'Number 199254=°1 Davie County Health Department County ID Number.5861-80-0318 210 Hospital StreetEvaluated For. NEW P.O.Box 848 :Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone:336-753-6780 Fax:336-753-1680 0 1 / a 0 / a 0 a 1 Applicant: Jerry W.Grubbs r roperty Owner. Patricia Chaffin Grubbs Address: 107 Inland Court ddress: 107 Inland Court Cky: Kelnersville City: Kemersville StatefZip: NC 27284 StatefLip: NC 27284. Phone#: one (336)784-4668 (336)784-4668 Ph #: Property Location & Site information Address/Road#: Subdivision: Phase: Lot: Baltimore Road Advance NC 27006 Directions Structure: SINGLE FAMILY Hwy 158 East right on Baltimore Road second property on right past Juney Beauchamp Rd #of Bedrooms: 2 #of People: "Water Supply: EXISTING WELL System Specifications Minimum Trench Depth: a 4 Site Classification: Provisionally Suitable Inches Minimum Soil Cover. 1 a Saprolite System? OYes *No Inches Design Flow: 2 4 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 , a Maximum Soil Cover: a 4 Inches *System Classification/Description: "Distribution Type: GRAVITY-SERIAL TYPE IIA.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: Gallons 'Proposed,System: 25%REDUCTION 1-Piece: OYes ONo Pump Required: QYes (J)No 0May Be Required Nikrification Field 1 a 0 0 Sq.ft. Pump Tank: Gallons No.Drain Lines a 1-Piece:OYes ONo Total Trench Length: 3 0 0 ftGPM vs— ft. TDH Trench Spacing: _ 9 2inches O.C. Dosing Volume: _ Gallons Feet O.C. Trench Width: _ 3 s Q Inches Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-11 Septic Tank Installer Grade Level Required:.01 011 0111 OIV` Donn 1 of 4 CDP File Number 199254 - 1 County ID Number. 5861-80-0318 . ❑ Open Pump Systbm Sheet Repair System Required:OYes ONO @No, but has Available Space rDesign System Q Inches 0. . Trench Spacing: Q ification: Provisionally Suitable 9 Feet O.C. Q Inches w: a 4 Trench Width; _ 3 Feet Soil Application Rate: 0 - a Aggregate Depth: inches `r Minimum Trench Depth: 2 4 "System Classification/Description: Inches TYPE II A CONY SYSTEM(SINGLE-FAMILY OR 980 GPD OR LESS) Minimum Soil Cover. 1 a Inches' Maximum Trench Depth: 3 6 Inches "Proposed System: 2.5%,REDUCTION Maximum Soil Cover: � 4 Nitrification Field 1 a 0 Inches Sq.ft. No. Drain Lines "Distribution Type: GRAVITY-SERIAL a TotalTrench Length: 3 � � �. Pump Required: OYes ®No May se Required Pre Treatment: ONSF OTS-I OTS-II .Site Modifications No grading or construction activity is allowed in areas designated for system and repairwithout 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 forwastewater System Construction shall bevarld fora person equal to the period of validity of the improvement Permit,not to exceed five years,and maybe Issued at the sametime the Improvement Permit issued(NCGS 130A-336(b)}If the Installation has notbeen completed during the period d 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 changed,or the site Is altered,the permit orConstruction Authorization shall become Invalid,and maybe suspended or revoked(.1937(g)).The person owning or controlling 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 (1938(b)). _ - Applicant/Legal Reps. Signature Required? Oyes ONO Applicant/Legal Reps.Signature, Date: Issued By: Date of issue: 2140-Nations,Robert 0 1 / a 1 j a 0 1 6 . W 10117 Pool Authorized State Agent: Malfunction Log Oyes (+)Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 o_ .d. NEON 0 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number. 199254- 1 P.O.Box 84$ 5861.80-0318 Mocksville NC 27028 County File Number: Date: .0.1./ 21 / a@lb Click below to import an image from an extemal location: Drawing Type:Construction Authorization APEIC�" FO ITE EVALUATIONMaROVEMENT PERMIT & A15g� Davie County Environmental Health Date' Io-i P.O.Box 848/210 Hospital StreetSiT 6 Received 6 Det` Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 Application For: it8'S a Evaluation/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 UNLES S ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name Jam?g ti /.s� Gi f Contact Person JET U Address /©7 Home Phone 331- 7"J"/ y4 e�8' City/State/ZIP x,giZ .,✓,59sv,i/-- je Z7ZS V Business Phone Email .41'0x" Email: Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Comers Fla ed &S ,N MZ, 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.) 331, X//, 6607 Owner's Name Phone Number 7" 6(411- e Owner's Address /v7 G City/State/Zip k NERSvril.— A/t Z72Y PropertyAddress 3t( i.Lco2 t= City Lot Size a26p AC• Tax PIN# Subdivision Name(if applicable) S c,f,J�° Dirgct n/L `�}Dis To 'te: lel M-OI-L' PU- 0 I re urrv4u f� If the answel to any of the following questions is"Yes",supporting documentation must be attached: Are there any existing wastewater systems on the site? X Yes No Does the site contain jurisdictional wetlands? _Yes u No Are there any easements or right-of-ways on the site? _Yes a1-No Is the site subject to approval by another public agency? _Yes X No Will wastewater other than domestic sewage be generated? Yes X No IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms )A-Bathrooms Garden Tub/Whirlpool ❑Yes XNo Basement: es ONO Basement Plumbing: Oyes 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: ❑ County/City Water ❑New Well `B�sting Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?❑Yes 0 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 charges,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 or staking the house/facility location,proposed well location and the location of any other amenities. Site Revisit Charge Pr perry o er's or owner's legal representative signature Date(s): )Z Client Notification Date: Date EHS: a Sign given ❑Yes ❑No Account# Revised 11/06 Invoice# ---------- f"rr it'kk� r r` 51 ' ° 672 ,f - 711 1 5 Foil 71 5 738 I �'r//' u 249 I -- ----'r If I C7 75 f I 1� 787 t 97 1 I 1 r i - r _ --------------- --------------- -------- -----•---- m 49 �0 U N� sCW+ Printed:Dec 14, 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 CC/ ed �S;" Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 •7 Landscape position V Slope% HORIZON I DEPTH Q . Texture groupS' Consistence Structure Mineralogy HORIZON II DEPTH 5i--Lt, Texture group Consistence X it, 411fr Structure r Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION 5 LONG-TERM ACCEPTANCE RATE ,Y SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: �- OTHER(S)PRESENT: REMARKS: LEGEND Ludscane 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 Moist VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm 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 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-LonQ-term acceptance rate- ealldav/ft2 noun ncinc rne.a.ear