The URL can be used to link to this page

371 Cana Rd OPERATION PERMIT I or tIiceU§e-C7nry y Davie County Health Department *CDP File Number 218431 -1 - 210 Hospital Street P.O. Box$4$ County ID Number. Mocksville NC 27028 Evaluated For. NEW Phone:336-753-6780 Fax:336-753-1680 Township: FApplicant: Allen Sheets Property owner. Allen Sheets Address: 1234 Woodward Road Address: 1234 Woodward Road City: Mocksville City: Mocksville State2ip: NC 27028 State[Zip: NC 27028 Phone#: (336)682-2591 Phone#: (336)682-2591 Property Location & Site Information rAddressfRoad#: - Subdivision: Phase: Lot: Lane le NC 27028 Directions structure: SINGLE FAMILY 601 North right on Main Ch Rd. left on Cana Rd. left on Channel lane #of Bedrooms: 3 #of People: 2 *Water Supply: PUBLIC *IP Issued by. 2140-Nations,Robert *System Classification/Description: *CA issuld by: 2140.Nations,Robert Saprolite System? 0Yes Flo Design Flow: 3 6 0 GRAVITY-SERIAL Pump Required? Distribution Type: QYes (E)No Soil Application Rate: 0 - 3 *Pre Treatment: Drain field rNo. cation Field 1 2 0 0 Sq.ft. *System Type: INFILTRATOR QUICK 4 STANDARD rain Lines 3 Installer: Rusty Miller Total Trench Length: 3 0 0 11t• Certification#: 1129 Trench Spacing: — 9 Inches O.C. • Feet O.C. *EH S: 2140-Nations,Robert Trench Width: 3Inches geet Date: 0 7 / 1 4 / 2 0 1 6 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. 4 ApprovaCStatus Inches Maximum Trench Depth: 3 6 ® Approved O Disapproved Inches s Maximum Soil Cover: 2 4 Inches CDP File Number 218431 - 1 County ID Number: Septic Tank ' Manufacturer Shoaf Lat. STB: 760 Long= Gallons; 11)00 Installer. Rusty Miller Certification#: 1129 Date: 0 5 / 0 6 / x 0 1 6 *EHS: 2140-Nations,RobeId *Filter Brand: POMOK PLA 22 With Pipe Adapter ST Marker. ❑ Yes [E NO Date: 0 7 / 1 4 / 2 0 1 6 Reinforced Tank: ElYes 0 N0 Approval,, ta us s 1 Piece Tank: ❑ YeS Cl NO 0 Approved❑ Disapproved Pump Tank Manufacturer. Installer. PT: Certification#: Gallons: 'EHS: Date: / / Date. / 1 RiserSealed ❑ Yes ❑ No Riser Height: ❑ Yes ❑ No (Min.6 in.) Approval Status Reinforced Tank: ❑ Yes ❑ No p gpproved❑ Disapproved 1 Piece Tank: ❑ Yes ❑ No Supply Line Pipe Size: inch diameter Installer. Pipe Length: feet Certification#: *Schedule: *EH S: Pressure Rated ❑ Yes ❑ No Date: Approved fittings [IYes ElN No Approval Status ❑ Approved❑ Disapproved Pump e ui e Pump Type: Installer. Dosing Volume: — Gal Certification#: Draw Down: Inches 'EHS: *Chau: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ NO Check-valve ❑ Yes ❑ NO Approval'Status PVC unions El Yes El No ❑ Approved C7 Disapproved,, Vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ Yes 0 No CDP File Number 218431 - 1 County.ID Number: Electric Equipment NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer: Box 12 inches Above Grade ❑ Yes ❑ No Box Adj.To Pump Tank Certification : ❑ Yes ❑ N o Conduit Sealed ❑ Yes ❑ No 'EHS: Pump Manually Operable ❑ Yes ❑ No 'Activation Method: Date: Approval Status Alarm Audible El Yes ❑ No p Approved❑ Disapproved Alarm Visible ❑ Yes ❑ No 2140-Nations.Robert *Operation Permit completed by: Authorized State Agen Date of Issue: 0 3 / 1 4 / 2 0 1 6 _ Owner/Applicant Signature: This system has been installed in 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 sewage septic system. Rule.1961 requires that a Type septic system meet the following criteria: Minimum System Review ByThe Local Health Department: Management Entity: Maximum System Inspection/Maintenance Frequency By Certified Operator: Reporting Frequency By Certified Operator. 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 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 218431 - 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: Olnch Drawing Drawing Type: Operation Permit Scale:. , OOcei A k 1 I I �' l � CONSTRUCTION For office use only AUTHORIZATION *CDP File Number 218431 -1 Davie County Health Department County ID Number. 210 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 5 / a 7 / a 0 a 1 Applicant: Allen Sheets r roperty Owner: Allen Sheets Address: 1234 Woodward Road ddress: 1234 Woodward Road City: Mocksville CRY: -Mocksville StaterLip: NC 27028 State2ip: NC 27028 Phone#: (336)682-2591 Phone#: (336)682-2591 - Property Location a Site Information C4Address/Road#: Subdivision: Phase: Lot: hannei- ane CANrt 0ocksville NC 27028 Directions 601 North right on Main Ch Rd. left on Cana Rd. left on . Structure: SINGLE FAMILY Channel lane #of Bedrooms: 3 #of People: 2 '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 5Incties Soil Application Rate: - 0 . 3 Maximum Soil Cover: R 4 Inches "System Classification/Description: 'Distribution Type: TYPE II 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.ft. Pump Tank: Gallons No. Drain Lines a 1-Piege: OYes ONo Total Trench Length: 3 0 0 ft ' GPM—vs— ft. TDH Trench Spacing: — 9 Onches O.C. Feet O.C. Dosing Volume: Gallons Trench Width: — Inches 3 Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-II Septic Tank Installer Grade Level Required: 01011 0111 01V CDP File Number 218431 - 1 County ID Number. ❑ Open Pump System Sheet Repair System Required:@Yes ONO ONO, but has Available Space rDesign System Trench Spacing: 9 O Inches O. . ification: Provisionally Suitable Q Feet O.C. Trench Width: Inches w: 3 6 _ 3 . g Feet et Depth; Application Rate: 0 _ 3 inches *System Classification/Description: Minimum Trench Depth: a 4 Inches TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. 1 a Inches *Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Nitrification Field 1 a 0 0 Sq.ft. Maximum Soil Cover: a 4 Inches No. Drain Lines *Distribution Type: GRAVITY-SERIAL a , Total Trench Length: 3 0 0 ft Pump Required: OYes ONo 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. "Permit Conditions The issuance ofthis 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 be valid for a 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 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 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: 2140-Nations,Robert Date of Issue: . 0 5 / a 7 / a 0 1 6 Authorized State Agent: Malfunction Log Oyes ®Hand Drawing OlmportDrawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: 0 5 / 2 7 / 2 0 1 6 . Q Inch Drawing Drawing Type: Construction Authorization Scale: . ON/A01310 = ft. QN/ I I� �1 0 �-- / 4 1 1I 1-7 F i � CONSTRUCTION AUTHORIZATION Davie County Health Department .y 210 Hospital street CDP File Number: P.O.Sox 848 Mocksville NC 27oz8 County File Number: Date: 05 / a7 I2016 Click below to import an Image from an external location: Drawing Type:Construction Authorization �`r ' IMPROVEMENT PERMIT ForOffice Use Only *CDP File Number. 218431 -1 �- � Davie County Health Department County ID Number. 210 Hospital Street P.O. Box 848 Evaluated For. NEW Mocksville NC 27028 Township: ., Phone: 336-753-6780 Fax:336-753-1680 "•� PERMIT VALID UNTIL 5/27/2021 T*NOTE TO INSPECTIONS DIVISION: Building Permits cannot be Issued with this Improvement Permit. . Applicant: Allen Sheets Property owner. Allen Sheets Address: 1234 Woodward Road Address: 1234 Woodward Road City: Mocksville City: Mocksville StatefZip: NC 27028 State/Zip: NC 27028 Phone#: (336)682-2591 Phone#: (336)682-2591 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: Channel Lane Mocksville NC 27028 Directions Structure:. -. : SINGLE FAMILY _ 601 North right on Main Ch Rd. left on Cana Rd. left 9 of Bedrooms: 3 on Channel lane #of People: 2 *Water Supply: PUBLIC System Specifications 75 it system *S ite?`lassification: Provisionally Suitable Minimum Trench Depth: a 4 Inches Saprolite System? QYes QNo Maximum Trench Depth: 3 5 Inches Design Flow: 3 6 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 0 _ 3 1-Piece: QYes QQ N o Pump Required: QYes 0N 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-Piece: QYes QNo Repair System Required:@Yes ONO ONo, but has Available Space Repair System *Site Classification: Provisionally Suitable Minimum Trench Depth: a 4 Inches Soil Application Rate: 0 - 3 Maximum Trench Depth: 3 6 Inches *System Classification/Description: Pump Required: QYes QNo Q Maybe Required TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System: 25%REDUCTION Pagel of 3 CDP File Number 218431 - 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 ofthis 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. Site Plan The 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 and proposed property lines with dimensions,the location of the facility and appurtenances,the s site for the proposed Wastewater system,and the location of water supplies and surface waters). Plat The improvement Permit shall be valid without expiration with plat(means a property surveyed prepared by a registered land O surveyor,drawn to a scale atone inch equals no more than 60 feet,that Includes:the specific location of the proposed facility 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 platthat 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 far failure of the system to satisty the conditions,the rules,or this article.This permit is sulgect to revocation if the site plan,plat,or intended use changes(NCGS 130A-336(t)).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: 2140-Nations,Robert Date of Issue: 0 5 / 2 7 / 2 0 1 6 Authorized State Agent: OValid without Expiration? OCreate CA? @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 . IMPROVEMENT PERMIT 218431 - 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: Olnch Block Drawing Drawing Type: Improvement Permit Scale: , O _ QN/A �Q �d I 1 __ . �1 --IFF---11-- --}-•-}- _-, .__-_ d I I I IMPROVEMENT PERMIT y Davie County Health Department 210 Hospital Street CDP File Number: 218431 - 1 P.O.Box 848 Mocksville NC 27028 County File Number: Date: 85 / 27 / 2016 Click below to Import an image from an external location:Drawing Type: Improvement Permit APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT&ATC ��y Davie County Environmental Health P.O.Box 848/210 Hospital Street-- �.�`� Mocksville,NC 27028. (336)753-6780/Fax(336)753-1680 Application For. Site Evaluation/Improvement Permit C Authorization To Construct(ATC) ❑Both Type of Application: ❑New System ❑Repair to Existing System 7Expansion/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 A I k t(0 S�c e i-S Contact Person le ri Address I'Z3< t?4 Home Phone 3 34 2<- City/State/ZIP 1'hoc kSd, )1 e- fu P �:2 7tl 24Z Business Phone 33(, 4 RX -3G7 Email 1,c e- s r-I . Email: Name on Pertnit/ATC if Dif rent than Above Mailing Address S A^% f— City/State/Zip U W C 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 SAAA e!� Phone Number Owner's Address City/State/Zip Property Address .hautyE jt/e- city.& ,1kl UC-11a Lot Size Tar PIN# Subdivision Name(if a plicable) f S tion/LoO D• ctions To ite: If the answer to any of the following questions is"Yes",supporting documentation must be attached: Are there any existing wastewater systems on the site? Yes No Does the site contain jurisdictional wetlands? _Yes No Are there any easements or right-of-ways on the site? Yes No Is the site subject to approval by another public agency? _Yes No Will wastewater other than domestic sewage be generated? Yes No IF RESIDENCE FILL OUT THE BOX AELOW #People G 4 #Bedrooms #Bathrooms Garden Tub/Whirlpool I IYes INo Basement::]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: oLb 5 entional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ty/City Water ❑New Well ❑Existing Well 7 Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?C Yes ❑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 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 or staki g t e ho I facility loci on,pro edwell location and the location of any other amenities. / � CQ Site Revisit Charge Prop w oner s or owner's legal representative signature Date(s): Client Notification Date: Date EHS: Sign given I Yes❑No Account# Revised 11/06 Invoice# ' 5388 F9325 ., ., I h 731 a 461 N i r r rr f1W3mf1!W XRAC7 t fr 0020 !' '^ 162 r�.. ` 436'' 4 0113 pjA) *`1 j. -147- a fr t 366 ,fl lL4''s Nj 1390 ria 0 �r <_ 347r Y a 7006 3030! 358 4�a�t1"' UR s Printed:Apr 12, 2016 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 dan'hd ( C -3 J(P RZM �Dll3 Water Supply: On-Site Well Community Public Evaluation By: Auger Boring / Pit Cut FACTORS 1 2 3 4 5 6 -7 Landscape position v C✓ Slope% HORIZON I DEPTH _� O Texture group e Consistence Q - Structure 5 iG 5-6 Mineralogy HORIZON H DEPTH Texture group Consistence - Structure Mineralogy 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 QS SITE CLASSIFICATION: EVALUATION BY• LONG-TERM ACCEPTANCE RATE: V OTHER(S)PRES Z 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 CONSISTENCE - Moist VFR Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm 3Y91 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 gram .' M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK Subangularblocky' PL-Platy PR-Prismatic 17 Mineralogy 1:1,2:1,Mitred ,1*✓ K , f In inches Horizon depth- Depth of fill-In inches Restrictive Iionzon.-TlucicnSss and inches from land surface r ` Sa rolite S suitable),U ) h P ( (prisiutable %% ........'.� ,:` •{ , i , '. ' `� -. Soil wetness'-Inches fromland surl'a6e to free water or inches"frAm land'surface to soil colors with chrom,2 or less ,r Classification-S(suitab`le),PS(provisignally suitable),.U(unsuitable) ✓�r.' ` LIAR-Lon'_ acceptance rate eal/day/ftp r '_ inr,u ti ncm�,/n4 va. _ -