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813 Hwy 801N OPERATION PERMIT` or ice se ny Davie County Health Department *CDP File Number 20199T-1 210 Hospital Street 5862670238 P.O. Box 848 County ID Number. Mocksville NC 27028 Evaluated For.`NE Phone:336-753.6780 Fax:336-753-1680 Township: Applicant: Evan Hodges Property Owner: Louis Cope Address: 104 Cope Road Address: 104 Cope Road City: Advance City: Advance StatefLip: NC 27006 State0p: NC 27006 Phone#: (336)251-7190 1,Phone#: (336)251-7190 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: 104 Cope Road Advance NC 27006 Directions Structure: SINGLE FAMILY 140,'Exit 180 take a left and go up 801 north 1.5 miles Cope Rd on the Left #of Bedrooms: 3 #of People: 3 *Water Supply: PUBLIC *IP Issued by. 2140-Nations.Robert *System Classification/Description: *CA issued by: 2140-Nations,Robert SaproliteSystem? QYes QNo Design Flow: -3 6 0 _Distribution Type: GRAVITY-SERIAL Pump Required? QYes QNo Soil Application Rate: 0 3 a 5 *Pre Treatment: Drain field (No. drification Field 1 1 0 8 Sq.ft. *System Type: INFILTRATOR QUICK STANDARD Drain Lines 3 Installer: Tony Batt Total Trench Length: a 7 8 ft. Certification#: 4700 Trench Spacing: — 9 Inches O.C. &Feet O.C. *EH S: 2140-Nations,Robert Trench Width: 3Inches gFeet Date: 0 9 / a a / 2 0 1 6 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4 Inches Approval Stat'6s' Maximum Trench Depth: 3 6 Inches ® .Approved Disapproved Maximum Soil Cover. 2 4 Inches CDP File Number 201997- 1 Septic Tank County ID Number: 62670238 , Manufacturer. $hoaf Lat. STB: 760 Long: . Gallons: 1000 Installer: Tony Ball Date: 0 6 / 2 7 / 2 0 1 6 Certification#: 4700 'EHS: 2140-Nations,Robert 'Filter Brand: POLYLOK Dual PL-122 With Pipe Adapter ST Marker: El Yes ® NO Date: 0 . 9 / 2 a / 2 0 1 6 Reinforced Tank: ❑ Ye5 ® No Approval Status 1 Piece Tank: D .Yes O No ® Approved "Disapproved Pump Tank Manufacturer. Installer PT: Certification#: Gallons: THS: Date: / / Date. RiserSealed ❑ Yes ❑ No RiserHeght: ❑ Yes ❑ No (Min.6 in.) ApprelStatus PP pp Reinforced Tank: ❑ Yes ❑ No, ❑ A ,= rove�dD Disa ` rove"d, 1 Piece Tank:_❑ Yes ❑ No Supply Line Pipe Size. inch diameter Installer. Pipe Length: feet Certification#: i "Schedule: 'EHS: Pressure Rated. ❑ Yes ❑ No Date: Approved fittings ❑ Yes ❑ NO Approval Status Cl Approved❑ Disapproved Pump Requirement Pump Type: Installer: Dosing Volume: — Gal Certification#: Draw Down: Inches THS: 'Chain: Date: Valves Accessible ❑ Yes ❑ NO Flow Adjustment Valve ❑ Yes ❑ NO Check-valve ❑ Yes ❑ No Approval Status r. PVC unions E] Yes ❑ No D `Approved❑ Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ Yes 0 No CDP File Number 201997 - 1 County ID Number: 5862670238 Electric Equipment (NEMA4X Box or Equivalent El Yes ❑ No Installer: Box 12 inches Above Grade El El No Certification#: Box Adj. Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No *EHS: Pump Manually Operable ❑ Yes ❑ No *Activation Method: Date: _ "Approval St,afus Alarm Audible ❑ Yes 13No ❑.ApproveD Alisapproved.§= Nam Visible ❑ Yes �.Wo. 2140-Nations,Robert *Operation Permit completed by: Authorized State Agent: Date of Issue: 0 9 a s 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 sewage septic system. Rule.1961 requires that a Type septic system meet the following criteria: - Minimum System Review By The Local Health Department: Management Entity: Minimum System Inspection/Maintenance Frequency ByCertified 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 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 entAy 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 201997 - 1 Davie County Health Department CDP File Number: 210 Hospital Street 5862670238 P.O.Box M County File Number: Mocksville NC 27028 Date: ! / Q Inch Drawing Drawing Type: Operation Permit Scale: ON A k = ft. + 1-6 I � 1 +1 I N ,, qj( 4zrc l I _ ho 1 t i .......E . i f CONSTRUCTION For office Use Only AUTHORIZATION "CDP File Number 201997-1 Davie County Health Departrrler �p County ID Number.5862670238 210 Hospital Street Evaluated For. NEW .� �,. P.O. Box 848Dnp; a Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax:336-753-1680 0 5 / a 3 / a 0 a 1 Applicant: Evan Hodges Property Owner: Louis Cope Address: 104 Cope Road Address: 104 Cope Road Cdy: Advance City: Advance StatefZip: NC 27006 State/Zip: NC 27006 Phone#: (336)251-7190 Phone#: (336)251-7190 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: 104 Cope Road Advance NC 27006 Directions Structure: SINGLE FAMILY 1-40, Exit 180 take a left and go up 801 north 1.5 miles #of Bedrooms: 3 Cope Rd on the Left #of People: 3 `Water Supply: PUBLIC System Specifications Minimum Trench Depth: a 4 rDesign ation: Provisionally suitable 71nchesem? Yes Minimum Soil Cover. 1a Q QNo 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 . 3 a 5 Maximum Soil Cover: a 4 Inches 'System Classification/Description: 'Distribution Type: GRAVITY-SERIAL TYPE 11 A CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: ]. 0 0 0 _ Gallons 'Proposed System: 25%REDUCTION 1-Piece: QYes QNo Pump Required: QYes QNo QMay Be Required Nitrification Field 1 1 0 8 Sq. ft. Pump Tank: . Gallons No.Drain Lines 3 1-Piece: QYes QNo Total Trench Length: a 7 7 ft GPM vs— ft. TDH Trench Spacing: _ 9 Weches t O.C.C.0 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: 01011 O 111 01V Donn 4 of Z CDP File Number 201997 - 1 County ID Number: 5862670238 , ❑ Open Pump System Sheet Repair System Required:@Yes ONO ONO, but has Available Space rDesign System Trench Spacing: 9 Inches 0.0 ification: Provisionally Suitable �,03 Feet O.C. Trench Width: Inches w: 3 6 0 3 Feet Soil Application Rate: 0 3 a 5 Aggregate Depth: inches Minimum Trench Depth: a 4 *System Classification/Description: 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: 6 Inches Nitrification Field 1 1 0 : $ Sq.ft. Maximum Soil Cover: a 4 Inches No. Drain lines *Distribution Type: GRAVITY-SERIAL 3 -Total Trench Length: a 3 7` ft. Pump Required: Oyes @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 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 bevalid fora person equal to the period of validity of the improvement Permit,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 orchanged,orthe site is altered,the permit or Construction Authorization shall become Invalid,and may be suspended or revoked(.1937(g)).The person owning orcontrolling 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: *Issued By: 2310-Debra Hames Date of Issue: . 0 5 / a 3 / a 0 1 6 Authorized State Age Malfunction Log OYeS ; @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION 201997 - 1 Davie County Health Department CDP File Number: 210 Hospital Street 5862670238 P.O.Box 848 County File Number: Mocksville NC 27028 Date: 0 5 / -� 3 / a 0 1 6 Q Inch Drawing Drawing Type: Construction Authorization Scale: , OBlock ON/A ILII I I l I -+4+-H ! I - -�"3 - Sz�- 1 t Y1 � t I I i I 1 I I ► � I I � � I ��! I j , ; CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital street CDP File Number: 201997 - 1 P.O.Box 84$ 5862670238 Mocksville IVC 2702$ County File Number: Date: .0 .5 / 23 / .1 0 1 6 Click below to Import an image from an external location: Drawing Type:Construction Authorization ' For Office Use Only IMPROVEMENT PERMIT =CDPFteNumber 201997- 1 r"t• Davie County Health Department 1^ County ID Number.5862670238 _ 210 Hospital Street ��1\ P.O.Box 848 �1 Evaluated For. NEW Mocksville NC 27028 Township: Phone:336-753-6780 Fax:336-753-1680 pERkI1T VALID UNTIL 4/7/2021 "NOTE TO INSPECTIONS DIVISION: Building Permits cannot be Issued with this Improvement Permit. Applicant: Evan Hodges Property Owner: Louis Cope Address: 104 Cope Road Address: 104 Cope Road Cty: Advance City: Advance State/Zip: NC 27006 State/Zip: NC 27006 Phone#: (336)251-7190 Phone#: (336)251-7190 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: 104 Cope Road Advance NC 27006 Directions Structure: SINGLE FAMILY 1-40, Exit 180 take a left and go up 801 north 1.5 #of Bedrooms: 3 miles Cope Rd on the Left #of People: 3 'Water Supply: PUBLIC System Specifications rSde nitial System iassTicatan: Provisionally SuitableMinimum Trench Depth: a 4 Inches olite System? OYes QNo Maximum Trench Depth: 3 6 Inches Design Flow: 3 6 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 0 . 3 2 5 1-Piece: OYes ONo 'System Classification/Description: Pump Required: OYes QNo OMay Be Required TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons LESS) 'Proposed System: 25%u REDUCTION 1-Piece: OYes ONo Repair System Required:@Yes ONo ONo, but has Available Space Repair System CS e Classification: Provisionally Suitable Minimum Trench Depth: 2 4 Inches l Application Rate: 0 3 2 5 Maximum Trench Depth: 3 6 Inches u "System Classification/Description: Pump Required: OYes QNo 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 201997 - 1 County ID Number: 5862670238- ' , *Site Modifications ❑ Open Fill Sheet No grading or construction activity is allowed in areas designated for system and repair without approval of Healtf!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 yearsfrom 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 Its 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 of one inch equals no morethan 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 for failure of the system to satisfy the conditions,the rules,or this article This permit is subject to revocation if the site plan,plat,or intended use changes(NCG5130A-335(f)).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 4 / 0 3 / a 0 1 6 Authorized State Agent: OValid without Expiration? 0Create CA. ®Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 IMPROVEMENT PERMIT 201997 - 1 Davie County Health Department CDP File Number. 210 Hospital Street 5862670238 P.O.Box 848 County File Number: Mocksville NC 27028 Date: Q Inch Drawing Drawing Type: Improvement Permit Scale: QBlock �3 ON/A ft. II I ------ ------------ I -----1- _ . ---- I_ ---- I II � a _ Z �I ------------ Illillll I I I � I Id� I � � � � I� I � � � I I � ► I IMPROVEMENT PERMIT Davie County Health Department 210 Hospital Street CDP File Number: 201997 - 1 P.O.BOX W 51362670238 Mocksvilte NC 27028 County File Number: Date: 04 / 07 / 2016 Click below to import an image from an external location:Drawing Type: Improvement Permit ..APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Davie Ctaunty Etsvfronmtntal Htalth P.O.Boz 828/21 D IfospltalStreN' bliocksvitic,.NC.170211 ..(330753-6780/Fax(336)733.1680: . . Application For-, Site>rvaluati mprovernentPcmtit AuthorisstiatToConsvue(ATC1 Both Type ofApplieation: ew rsum Repair to Existing System Expaasson/nlodificaaon o istutg System or Facility •••/AIP0RTA1YT•"THIS APPLICATION C V OTREPROCEEDUNLESSALLOFTHEREQUIRM INFORMATION IS!RAOVIDED. Rcrcr to the INFORMATIONN BULLETIN for instructions. APPLICANT INFORMATION Name m be Dillcd CA P S Contact Person Billing Address City/State/ZIP Business Phone Name on Pcmit/ATC ifDprrtnt than Above Mailing Address Ci IStatc/Zi PROPERTY INFORMATION *Date House/Facifty Corners Flagped NOTE: A survey plat or site plan must accompany this application. Included: Site Ftan plat(ta state) (Permit is valid for 60 months u-ith site plan,no expira(ion with complete p at.) Owners Name 1.O - Phone Number — LLo_8. Owners Address l�� p Ci /SrlLi FrPropertyA� �ddres)s o Cry ia V pej a7�ID Cot Size Cis_Z 1 O Subdivision Mroc(t�apf licabic) it Seedorvut Ditrctiorss To Sits; –1. o Oco If the answer to any of the following questions Is`yes",su documen-ion must be attached. Arc there any existing wastewater systems on the site? res oDoes the site contain jurisdictions]wetlands? NoAre their any eascrtrnts or right-ofways on the sue? NoIs the site subject to approval by ainother public agency? No Will wastewater other tame domestic sewaee be generated? Yes o IF RESIDENCE FILL OUT THE BOX BELOW k People p Bedrooms 8 Bathrooms 2_Cudcn Tub/1Vhirlpool Yes Basement:- Yes 50 Basement Plumbin : Yes o IF NON-RESIDENCE FILL OUTTHE BOX BELOW Facility/Business Total Square Footage of Building N People OS, odes 8 Showers N Uianats Estimated W a '' consumption) F RVIC6 ONLY: a Scats Typo system requested: Conventional Accepted Innmrative Altanatire Other, i Water Supply Type: Co City Water New WeU 'Existing Well i Community Well Do you anticipate additions of expansions of the facility this system is intended to srncl Yes No if ycs,what type? This is to certify that the information provided on this application Is true and eorroct to the best I f my knowledge. 1 undetsund that any pennil(s)of ATC(s)issued hereafter arc subject to suspension or sevocatmo n If the site ii 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 Mparunent to conduct necessary impectioas to dannine compliance with applicable laws and rules, I understand that I am responsible for the proper ldcntificaGon and labeling orpioperty lines ares]corners and locating and flagging or kin the housd/ cllity location,proposed well location and the location orany other a mcnities. �O t1t; "4+_1 f Site Re-visit Charge Pfoperty ownex's or owner's legal rcpraentanve*nature Client k 09V 1 Client 09V Date MIS: sign given Yes No Account Rcviud 11/06 , Invoice a t i i i pai i iative care center . 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House, a.px. 1`i� tDa ' ?C ` M rea O Ir y # 125 (206) 741 i ',� 1 147 FBD4,rr,G3 a 165 :C47 `b 7299= 3289 .. n 38 v (234) 207 140 148 i O.rrt ,- ,`• Ad dots Udm+kadsoIswftp4Awwnrtyorg"nr otu�yi�krdrhhwupttsWviapl6dk+ wwalbfANot Iffaw14V%w "d a Z IM �l1 t anRWiaaNe»estuntaerAyapmesstar•"Aursa�YtTwrnMDarlatruwtY�ttivn►alto tvaWMl�adauU+oCsw,tya! t Davlo Noetl WOins„Its st"lc,anwlAftow coMnctsnMamooysatftomy$"goculmslwtfwaio sewndwto"idsh*WAS# Pritlted:F@b 19 X016 Nowa u n McbOlty to s me GAS dau ynvMad by"waricna. , V� J r � (/vim DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION �Uatj k017 ac s � 1� 33(0 a5t .07 l a o Water Supply: On-Site Well Community Public �- Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 .7 Landscape position L Slope% Z_ HORIZON I DEPTH Q Z ¢- Texture group C, _-::5r C Consistence Structure 5 Mineralogy HORIZON H DEPTH 2 Y _&f Texture group Consistence S57<P-ft Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATIONAS LONG-TERM ACCEPTANCE RATE 1 SITE CLASSIFICATION: EVALUATION BY: Ej —e<,- LONG-TERM ACCEPTANCE RATE: Q • 7 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 CONSISTENCE - MQist 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 LY.oteS . 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-eal/dav/ft2 ntun nrunc tee..: ear Date Attendees Topic Meeting Objectives Notes y 3751 C Is 214�z �1 7—(4 G i 1 Action Items ❑ ❑ ❑ r l� S la �� a