454 Buck Seaford Rd • CONSTRUCTION For office use Only,
AUTHORIZATION *CDP File Number 188291 -1
Davie County Health Department County ID Number. K4-000-00-043.06
210 Hospital Street Evaluated For REPAIR
P.O.Box'848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 0 1 / 3 0 / a 0 a 0
Applicant: Jeff and Margie Smith Property Owner: Jeff and Margie Smith
Address: 454 Buck Seaford Rd Address: 454 Buck Seaford Rd
City: Mocksville City: Mocksville
State2ip: NC 27028 State/Zip: NC 27028
Phone#: (336)751-1438 Phone#: (336)751-1438
Property Location & Site Information
rAddress/Road#: Subdivision: Phase: Lot:
Seaford Road
e NC 27028 Directions
Structure: SINGLE FAMILY Harrison Rd. beside South Davie Jr High, left on Buck
Seaford.
#of Bedrooms: 3
#of People:
'Water Supply: NIA
System Specifications
Minimum Trench Depth:
rDesign
ssification: Provisionally Suitable Inches
Minimum Soil Cover.
System? OYes QNo Inches
low: 3 6 0 Maximum Trench Depth: Inches
Soil Application Rate: 0a Maximum Soil Cover: Inches
'System Classification/Description: `Distribution Type:
Septic Tank: Gallons
'Proposed System: 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: a 0 R GPM vs— ft. TDH
Trench Spacing: Inches O.C.
— 9 . @Feet O.C. Dosing Volume: _ Gallons
Trench Width: Inches
— 3 . "Feet Grease Trap: LGallonsAggregate Depth: inchesPreTreatment: ONSF OTS- -IISeptic Tank InstallerGrade Level Required: 01011 0111
Dana I ^f'A
CDP File Number 188291 - 1 .County ID Number.
K4-060-00-043-06
❑ Open Pump System Sheet
Repair system Required:OYes ONo ONo, but has Available Space
epair System Trench Spacing: Inches 0. .
"Site Classification: — V Feet O.C.
Trench Width: Inches
Design Flow: — Feet
Soil Application Rate: Aggregate Depth:. inches
Minimum Trench Depth:
*System Classification/Description: Inches
Minimum Soil Cover. Inches
Maximum Trench Depth:
*Proposed System: Inches
Maximum Soil Cover:
Nitrification Field Sq. inches
ft.
No. Drain Lines *Distribution Type:
Total Trench Length: ft. Pump Required: Oyes 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 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 for Wastewater System Construction shall bevalld for a person equal to the period of%mlldlty,of the Improvement Permit,not
to exceed five years,and maybe issued atthe sametime the lmprovement 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 or Construction Authodzatlon shall become
Invalid,and maybe suspended or revoked(.1937(g)).The person owning or controlling the system shall be responsible forassuring compliance
with the taws,rules,and permit conditions regarding system location,Installation,operation,maintenance,monitoring,reporting and repair
(1936(b)).
Applicant(Legal Reps.Signature Required? Oyes ONO
Applicant/Legal Reps.Signature: Date:,
* 2140-Nabons,Robert 0 1 / 3 0 / 2 0 1 5
Issued.By: Date of issue:
Authorized State Aged _ Malfunction Log OYes
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
` K4-000-00-043-06
CDP Fite Number 188291 - 1 County ID Number.
❑ Open Pump System Sheet
Repair System Required:OYes ONo 'ONo, but has Available Space
rDesign
System
Trench Spacing: �Inches 0. .
ification: — Feet O.C.
Trench Width: Q Inches
w: — Q Feet
SAggregate Depth:oil Application Rate: inches
Minimum Trench Depth: Inches
*System Classification/Description:
Minimum Soil Cover.
Inches
Maximum Trench Depth:
'Proposed System: Inches
Maximum Soil Cover:
Nitrification Field Inches
Sq.ft.
No. Drain Lines *Distribution Type:
TotalTrench Length: ft Pump Required: Oyes ONo OMay Be Required
Pre Treatment: O NSF OTS-1 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 by the Health Department in no wayguarantees the issuance of other permits.The permit holder
is responsiole forchecking with appropriate governing bodies in meeting their requirements. ;
This Authorization forWastewater System Constriction shall bevatid for a person equal to the period of unirdity of the improvement Perms;not
to exceed five years,and may be issued at the 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 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
Invalld,and may besuspended or revoked(.1937(g)).The person owning or controlling the system shall be responsible forassuring compliance
with the laws,rides,and permit conditions regarding system location,Installation,operation,maintenance,monitoring,reporting and repair
ApplicanttLegal Reps.Signature Required? Oyes ONO
i
Applicant/Legal Reps.Signature: _Date:.
*Issued By: 2140-Nations,Robert Date of Issue: - 0 1 3 0 P 0 1 5
Authorized State Age dZ �----- Malfunction Log OYeS
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
• CONSTRUCTION AUTHORIZATION
Davie county Health Department CDP File Number: 188291 - 1
210 Hospital StreetK4-000-00-043-06
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 0 1 / 3 0 / 2 0 1 5
Q Inch
Drawing Drawing Type: Construction Authorization Scale: OBlock
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DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST
APPLICATION IP/ATC OSWW REPAIR r�
Name d' �, I �"Il ' Telephone Number !51 - I L,I 3b
Address v
Mailing Address (if different from above) C
Email Address:
Subdivision Name Lot#
Directions Sk S. CDow pi� h t-e Nul uvG
Date System Installed Name System Installed Under
Type Facility Number Bedrooms_ Number People Served a
Type Water Supply '`rd' I Specific Problem Occurring
M
Date Requested , /:30 J Info Taken By
THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY
KNOWLEDGE,AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED
FROM THIS APPLICATION.
Signature of owner or Authorize Agent
Initial Fee �O U Date 0REHS r a,1 d Cash
Revisit Charge Date Reason I �S U�'�
Revised 2-2011
-'DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST
APPLICATION IP/ATC OSWW REPAIR
Name d' i' 0—;$m Telephone Number ILI S6
Ade�ss vV►1\e
Mailing Address (if different from above) MAL-
Entail Address: — -Q o -aa Name Lot#
Difections S. akw C 0 `� �� h.t c r� F�('.I' ) <
Q byl
Date System Installed Name System Installed Under
Type Facility Number Bedrooms -2j Number People Served a
Type Water SupplySpecific Problem Occurring c e t "
h c. —
Date Requested Info Taken By
THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY
KNOWLEDGE,AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED
FROM THIS APPLICATION.
Signature of owner or Authorized Agent
Initial Fee Date REHS
Revisit Charge Date Reason
Revised 2-2011
1,X0
DAVIF COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
"NOTE:Issued in Compliance Wit Pcfe I I'of S.Chapter 130a
Sanitary Sewage Syst s: ? PermiNumber
- Name !� Date _ d?-9Y N2 7681
Location ✓el 2 &,2L1JD—% J.�/�u�' / r�c�
Subdivision'Name Lot No. Sec. or Block No.`,
Lot.Size House _ Mobile Home _ Business __ Industry
No. Bedrooms S-V No. Baths—' _ No. in Family— Public Assembly Other
Garbage Disposal YES ❑ NO p' Specifications for System:
Auto Dish Washer YES NO ❑
Auto Wash Ma:hive YES NO p
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 iptended use change.
�2
Improvements 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:704-634-5985.
Final Installation Diagram: System Installed by
AAX°
-------------
r
Ce ificat of Completion Date � f
'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. .,