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1360 Bear Creek Church Rd (2) ' - OPERATION PERMIT or ficeulseunly Davie County Health Department *CDP File Number 219653171 rte. 210 Hospital Street P.O.Box 84$ County ID Number Mocksville NC 27028 Evaluated For. EXPANSION Phone:336-753-6780 Fax:336-753-1680 Township:. 7Address: t: Jeff Anderson Property owner. Jeff Anderson 1360 Bear Creek Church Rd Address: 1360 Bear Creek Church Rd y Mocksville city: Mocksville State)Zip: NC 27028 State/Zip: NC 27028 Phone#: (336)399-5412 Phone#: (336)399-5412 Property Location & Site Information rAddress/Road#: Subdivision: Phase: Lot: ar Creek Ch Rd le NC 27028 Directions Structure: SINGLE FAMILY Hwy 601 N. left on Liberty Church Rd to Bear Creek Church Rd #of Bedrooms: 3 #of People: *Water Supply: EXISTING WELL *IP Issued by. *System Classification/Description: TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140-Nations,Robert SaproliteSystem? OYes QNo Design Flow: 3 6 0 'Distribution Type: GRAVITY-SERIAL Pump Required? OYes (E)No Soil Application Rate: 0 - a 7 5 *Pre Treatment: Drain field rNo. on Field 1 3 0 9 Sq.ft. *System Type: INFILTRATOR QUICK 4 STANDARD n Lines a Installer: Sherman Dunn Total Trench Length: 1 1 a ft. Certification#: 2702 Trench Spacing: _ 9 21nches O.C. Feet O.C. *EH S: 2140-Nations,Robert Trench Width: 3 Inches Feet Date: 0 3 / 0 5 / 2 0 1 6 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4Approv6l.'Status Inches Maximum Trench Depth: 3 6 Inches ® 'Approved 0 Disapproved Maximum Soil Cover. a 4 Inches CDP File Number 219653 - 1 Septic Tank County ID Number: Manufacturer. Let. Long: STB: Installer Date: Certification#: 'EHS: "Filter Brand: ST Marker. ❑ Yes El No Date' Reinforced Tank: [:1Yes ❑ No Approval status 1 Piece Tank: ❑ Yes ❑ N o `O Approved❑ Dlsapproyed Pump Tank Manufacturer installer: PT: Certification#: .Gallons: *EHS: Date: Date: RiserSealed ❑ Yes ❑ No RiserHeight: ❑ Yes ❑ No (Min.6 in.) ApprbvalStiatus Reinforced Tank: ❑ Yes ❑ 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 ❑ Yes ❑ No Approval Status }© Approved© {D52, isapprove Pump e u Pump Type: Installer: Dosing Volume: — Gal Certification#: Draw Down: Inches "EHS: *Chain: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment valve ❑ Yes ❑ No Check-valve ❑ Yes ❑ NO "ApKoval Status� . PVC unions El Yes ElNo O Approved Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole El Yes 0 No CDP File Number 219653- 1 County ID Number: Electric E ui ment NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer. Box 12 inches Above Grade ❑ Yes ❑ No Certification#: Box Adj. Pump Tank ❑ Yes D No Conduit Sealed ❑ Yes ❑ No *EHS: Pump Manually Operable ❑ Yes ❑ NO *Activation Method: Date: Approval Status " Alarm Audible ❑ Yes ❑ No p Approved D Disapproved Alarm Visible ❑ Yes ❑ No 2140-Nation.Robert *Operation Permit completed by: Authorized State Agent: Date of Issue: 0 7 / 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 11 A. septic system meet the following criteria: Minimum System Review By The Local Health Department: N/A Management Entity: OWNER Minimum System Inspection/Maintenance Frequency By Certified Operator: N/A 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 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 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 shalt also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. OHand Drawing 41mport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT 219653 - 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: ! / Q Inch Drawiin� Dr wing Type: Op ration Permit Scale: �NiA k I I I j CONSTRUCTION For Office use Only • AUTHORIZATION *CDP FileNumber 219653-1 Davie County Health Department County.ID Number. 210 Hospital Street Evaluated For. EXPANSION .� �. P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone:336-753-6780 Fax:336-753-1680 0 6 / a 4 / a 0 a 1 Applicant: Jeff Anderson Property Owner. Jeff Anderson Address: 1360 Bear Creek Church Rd Address: 1360 Bear Creek Church Rd City: Mocksville City: Mocksville StatefZip: NC 27028 State/Zip: NC 27028 Phone#: (336)399-5412 Phone#: (336)399-5412 Property Location & Site Information Address/Road #: Subdivision: Phase: Lot: 1360 Bear Creek Ch Rd Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 601 N. left on Liberty Church Rd to Bear Creek Church Rd #of Bedrooms: 3 #of People: *Water Supply: EXISTING WELL System Specifications Minimum Trench Depth: a 4 rSaprolite ssification: ProvisionallySuitable Inches S stem? Minimum Soil Cover. 1 ay OYes (allo Inches low: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 . a 7 5 Maximum Soil Cover: a 4 Inches *System Classification/Description: *Distribution Type: Septic Tank: Gallons *Proposed System: 1-Piece: OYes ONo Pump Required: OYes ONo OMay Be Required Nitrification Field 1 3 0 9 Sq.ft. Pump Tank: Gallons No. Drain Lines 1 1-Piece: OYes ONo Total Trench Length: 1 0 9 ft GPM vs— ft. TDH Trench Spacing: ches O . _ 9 . Weet O.C. Dosing Volume: _ Gallons Trench Width: 3 . @Inches Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-II Septic Tank Installer Grade Level Required: 01 011 0111 OIV Doer ex I of Z CDP Fite Number 219653 - 1 County ID Number: ❑ Open Pump System Sheet Repair System Required:@Yes ONo ONo, but has Available Space rDesign System Trench Spacing: 9 Inches O.C. ification: Provisionally Suitable a Feet O.C. Trench Width: Inches w: 3 6 3 . ( Feet Soil Application Rate: 0 2 7 5 Aggregate Depth: inches Minimum Trench Depth: 2 4 *System Classification/Description: Inches TYPE 11 A.CONV SYSTEM(SINGLE-FAMILY OR 4130 GPD OR LESS; Minimum Soil Cover. 1 2 Inches 1 *Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches .— - _ _ Nitrification Field 1 3 0 9 Sq.ft. Maximum Soil Cover. a 4 Inches No. Drain lines *Distribution Type: GRAVITY-SERIAL 3 Total Trench Length: 3 a 7 ftPump Required: OYes @No OMay Be Required Pre Treatment: ONSF OTS-1 OTS-II *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. i *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. ; This Authorization for Wastewater System Construction shall bevalld fora 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 the application for a 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 revoked(.1937(g)).The person owning or controlling the systom 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)). Applicariftegal Reps. Signature Required? Oyes ONO Applicant/Legal Reps.Signature: Date: *Issued By: 7140-Nations,Robert Date of Issue: . 0 6 / 2 4 / 2 0 1 6 Authorized State Agent: Malfunction Log Oyes ®Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION 219653 - 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: 0 6 / 2 4 / 2 0 1 6 Q Inch Drawing DrawingType: Construction Authorization Scale: , OBlock = ft. . YP Q N/A Al - U , e JL- io ��r—p �. -., o � 1 .a- v Gf I j�lT CONSTRUCTION AUTHORIZATION - Davie County Health Department 210 Hospital street CDP File Number: 219653 - 1 P.O.Box 848 Mocksville NC 27028 County File Number: Date: 65 / 24 / 2016 Click bel w to importa Image from an external location: Drawing Type:Construction Authorization 1 t coo o rLf APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&P.' D D0vte County Enytronmental Henitlt Qj1",Cf` -P.O.Iior 848/210 Flospital Street. Moclsville,NC-27028 (336)753,6780/Far(336)753-1680 tea. Application For. 7 Site Evaluation/Improvement Permit C Authoryoltn To Construct(ATC) ❑Bot!r Type of Application: ❑New System ❑Repair to Existing System pansion/Modification of Existing System or- cility ***IMPORTANT"*THIS APPLICATION CAKNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name Contact Person AddressHome Phone City/State Business Phone Email Email: Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Comers Flagged NOTE: A survey plat or site plan must accompany this application. Included:U Site Plan UPlat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name Phone Number Owner's Address City/State/Zip Property Address /3(a A0,r �z/G 17 - City - Lot Size Tac PIN# Subdivision Name(if applicable) Section/Lotg, / Directio o-Site:_&ol R/ nw L,6 cd" Y ed. C U ES e-e r CL to If the answer to any of the following questions is"Yes",supportin.-5aumentation must be attached: Are there any existing wastewater systems on the site? _%-Yes —.�N Does the site contain jurisdictional wetlands? _Yes No Are there any easements or right-of-ways on the site? _Yes_ .. . -_. Is the site subject to approval by another public agency? Yes Will wastewater other than domestic sewage be generated? Yes No IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms #Bathrooms Garden Tub/Whirlpool I IYes INo Basement:7Yes ❑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 ❑Altemative ❑Other Water Supply Type:C County/City Water ❑New Well . sting Well 7 Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?C Yes -UO 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 sta-ino I house/fac•ity l tion, oposed well location and the location of any other amenities. Pr ty �� s or ier's legal representative signature Site Revisit Charge Date(s): Client Notification Date: Date v EHS: Sign given I Yes❑No Account# Revised 11/06 Invoice# � , IW DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 'NOTE:Issued in Compliance With Article II of G.S.Chapter 130a -fSanita S wa a Systems�fli�r�l— /* r 1 :y 1if,'� . Permit Number Dae ( Name i15N2 G«3 5 7Location 1360 Subdivision Name Lot No. Sec.or Block No. Lot Size 41ir— House Mobile Home Business Speculation No.Bedrooms____c�._No. Baths_ _ No.in Family , Garbage Disposal YES Q NO p• Specifications for System: Auto Dish Washer YES ❑ NO ❑ -e` J�c�IJ• Auto Wash Machine YES [7 NO Q Type Water Supply 'This permit Void it 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. F Improvements permit by 'k f� 'Contact a representative of the Davie County Health Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number:704-634-59655.. j Final Installation Diagram: System Installed by A 5 ° 7 i Certificate of Completion Date PA41 _ *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. NGDENR 'Division of Environmental Health On-Site Wastewater Section "Date: Soil/Site Evaluation *File#: a 1 9 6 5 3 For On-Site Wastewater System PIN 4: "OwnerJeffAnderson Proposed Facility SINGLE FAMILY Proposed Design Flow(.1949) 3 6 e Location of Site 1360 Bear Creek Ch Rd Property Size 17 Water Supply EXISTING WELL Evaluation Method n1a 1 40 Horizon SOIL MORPHOLOGY Profile# Lanscape Depth .1941 Other Profile Slo0e% IN Mineralogy Matrix Mottle Factors p ( ) Texture , Structure Consistence Color Color .1942 Wet. 0/0 .1943 Depth GPS Saprolite:(in) .1944 Rest. Horizon EHS .1947 Class Profile LTAR O •a� .1942 Wet. % ,1943 Depth GPS Saprolitcon) .1944 Rest. Horizon EHS .1947 Class Cop rotile P ofile LIAR .1942 Wet. % .1943 Depth GPS Saprolite:pn) .1944 Rest. Horizon EHS .1947 Class Copy rotile Profile ILTAR .1942 W et. % .1943 Depth GPS Saprolite:(ln) .1944 Rest. Horizon EHS .1947 Class Copy-11rofile Profile LTAR .1942 Wet. % .1943 Depth GPS Saprolite:(in) .1944 Rest. Horizon EHS .1947 Class Copy otle Profile PAR Available Space(.1945) S Other Factors(.1946) Ste Classification (.1948) Initial LTAR:_g. Repair LTAR:. 3' Others Present: Comments: I Evaluated By. Nations,Robert NCDENR Division of Environmental Health On-Site Wastewater Section Date: e 6 a / a e: .6 Soil/Site Evaluation Fie#: 2 2 9 6 53 For 0n-Site Wastewater System PIN 9: 14940 Horizon SOIL MORPHOLOGY Lan scape .1941 Other Profile Profile# Depth Sbpe ado (IN) Mineralogy, Matrix Mottle Factors Texture Structure Consistence Color Color 1942 Wet. % .1943 Depth GPS Saproldcon) .1944 Rest. Horizon EHS .1947 Class Copy-p-rofii Profile LTAR u • . .1942 Wet. % .1943 Depth GPS Saprolite:(n) .1944 Rest. Horizon EHS .1947 Class Copy�rofil Profile LTAR .1942 Wet. % .1943 Depth GPS Saprol4e:(n) .1944 Rest. Horizon .1947 Class EHS Copy tofu Profile LTAR_ • 1942 Wet, % .1943 Depth GPS Saprolite:(n) .1944 Rest. Horizon EHS .1947 Class Copy-Erofil Profile El LTAR .1942 Wet. % .1943 Depth GPS Saprolde:(n) 144 Rest. onzon EHS 1947 Class Copy„p rofil Profile ID- PAR LTAR Comments: Attach Image The "Open Drawing Form"button, opens the the drawing form. ( The "Import" button, attaches the drawing, or other image into the space below. Open Drawing Form Profile: Q X-- Profile: Profile: X Y Z Profile: X Y Z Profile: X Y Z Profile: X Y Z Profile: X Y Z Profile: X Y Z Profile: X Y Z Profile: I@ X Y Z Profile: X Y Z