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1106 County Home Rd OPERATION PERMIT FICDP ice use ny Davie County Health Department Number 157635- 1 3a� � 210 Hospital Street J4-0000002209 3 P.O. Box 848 County ID Number: EXPANSION Mocksville NC 27028 Evaluated For: Phone:336-753-6780 Fax:336-753-1680 Township: F ant: John Willis Property Owner: John Willis ss: 176 S. Madera Drive Address: 176 S. Madera Drive yMocksville CRY: Mocksville State2ip: NC 27028 State2ip: NC 27028 Phone#: (336)751-2668 Phone#: (336) 751-2668 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: 1106 County Home Rd Mocksville NC 27028 Directions Structure: SINGLE FAMILY Take Sanford Ave. runs into County Home Rd. 1st #of Bedrooms: 3 driveway at Bridge #of People: 'Water Supply: EXISTING WELL 'IP Issued by. 'System Classification/Description: TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) 'CA issued by: 2140-Nations,Robert Saprolite System? DYes Q No Design Flow: 3 6 0 'Distribution Type: Pump Required? DYes QNo Soil Application Rate: 0 - 2 5 'Pre Treatment: Drain field Nitrification Field 4 8 0 S4• ft. 'System Type: INFILTRATOR QUICK 4 STANDARD No. Drain Lines dt Installer: R-andy Miller and Sons Total Trench Length: 1 2 0 It. Certification#: Trench Spacing: 9 flinches O.C. _ Feet O.C. EH S: 2140-Nations,Robert Trench Width: _ 3 Qinches Feet Date: 0 9 / 0 9 / 2 0 1 4 Aggregate Depth: inches Minimum Trench Depth: 2 4 Inches Minimum Soil Cover. 1 2 Inches Approval Status Maximum Trench Depth: 3 6 Inches FS proved 0-Disapproved Maximum Soil Cover: a 4 Inches CDP File Number 157635- 1 County ID Number: A-0000002209 Septic Tank Manufacturer. Lat. Long: STB: ' Gallons: Installer: Date: / / Certification#: 'EHS: *Filter Brand: ST Marker: ❑ Yes ❑ NO Date: Reinforced Tank: ❑ Yes ❑ NO Approval Status 1 Piece Tank: ❑ Yes ❑ No ❑ Approved❑ Disapproved Pump Tank Manufacturer. Installer: PT: Certification#: Gallons: 'EH S: Date: / / Date: Riser Sealed ❑ Yes ❑ No RiserHeght: ❑ Yes ❑ No (Min.6 in.) Approval Status Reinforced Tank: E] Yes E3 No ElApproved❑ Disapproved 1 Piece Tank: ❑ Yes ❑ No Supply Line Poe Size: inch diameter Installer. Poe Length: feet Certification#: *Schedule: *EHS: Pressure Rated ❑ Yes ❑ NO Date: Approved fittings ❑ Yes ❑ NO Approval Status ❑ Approved❑ Disapproved Pump Requirement 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 Approval Status PVC unions ❑ Yes ❑ No ❑ Approved❑ Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ Yes ❑ No CDP File Number' 157635 - 1 County ID Number: A-0000002209 Electric Equipment NEMA 4X Box or Equivalent (3 Yes ElNo Installer. Box 12 inches Above Grade ❑ Yes ❑ No Certification#: Box Adj.To Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No "EHS: Pump Manually Operable ❑ Yes ❑ No "Activation Method: Date: Approval Status Alarm Audible 11 Yes E3No El Approved El Disapproved Alarm Visible El Yes ❑ NO 2140-Nations,Robert =Operation Permit completed by: Authorized State Age�� j? ate of Issue: 0 9 / 1 0 x 0 1 4 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 II 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_ WA Reporting Frequency By Certified Operator: N/A Rule .1961 requires that a Type IV and V septic systems designed fora hometbusiness 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 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. K shall also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. OHand Drawing Olmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT 157635 - 1 Davie County Health Department CDP File Number: 210 Hospital Street county File Number: 0000Ri09 P.O.Box 848 nmax ec Haze pa p n Dry $ea r Drawing Operation le: OBlock A. 06 III I io CONSTRUCTION For office use Only AUTHORIZATION *CDP File Number 157635-1 -= ' Davie County Health Department County ID Number:J4-0000002209 ( 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 9 / 1 0 a 0 1 9 Applicant: John Willis Property Owner. John Willis Address: 176 S. Madera Drive Address: 176 S. Madera Drive City: Mocksville City: Mocksville State2ip: NC 27028 State/Zip: NC 27028 Phone#: (336)751-2668 Phone#: (336)751-2668 Property Location & Site Information rAddress/Road #: Subdivision: Phase: Lot: nty Home Rd e NC 27028 Directions Structure: SINGLE FAMILY Take Sanford Ave. runs into County Home Rd. 1st driveway at Bridge #of Bedrooms: 3 #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? DYes QNo Inches Design Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 a 5 Maximum Soil Cover: a 4 Inches *System Classification/Description: `Distribution Type: TYPE 11 A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: Gallons *Proposed System: 25%REDUCTION 1-Piece: OYes ONo Pump Required: DYes QNo OMay Be Required Nitrification Field 4 a 8 Sq. ft. Pump Tank: Gallons No. Drain Lines a 1-Piece: DYes ONo Total Trench Length: 1 a 0 ft GPM—vs— ft. TDH Trench Spacing: _ 9 gInchtes C.0 Dosing Volume: _ Gallons Trench Width: 3 gInches Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-II Septic Tank Installer Grade Level Required: 01011 0111 OIV Pagel of 3 CDP File Number -157635 - 1 County ID Number: 14-0000002209 ❑ Open Pump System Sheet Repair System Required:Wes ONO ONo, but has Available Space rDesign System Trench Spacing: Inches O. . ification: Provisionally Suitable — 9 a Feet O.C. Trench Width: Q Inches w: 3 6 0 — 3 Feet Soil Application Rate: 0 - a 5 Aggregate Depth: 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 Maximum Trench Depth: 3 6 Inches *Proposed System: 25%REDUCTION - Nitrification Field 1 4 4 0 Sq.ft. Maximum Soil Cover: a 4 Inches No. Drain Lines 3 'Distribution Type: GRAVITY-PARALLEL(eq.d-box) Total Trench Length: 3 6 0 ft Pump Required: QYes 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 repair without approval of Health Department. 7! '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. 404 2( This Authorization for wastewater System Construction shall bevalid for a person equal to the period of wlidity of the Improvement Permit not to exceed five years,and may be issued atthe 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 theapptication for a permit or Construction Authorization is found to have been Incorrect,falsified or changed,or the site Is attered,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 forassuring 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 9 i' 0 8 .2 0 1 4 Authorized State Agent: Malfunction Log OYes OHand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION 157635 - 1 Davie County Health Department CDP File Number: 210 Hospital Street County File Number: J4-0000002209 P.O.Box 848 Mocksville NC 27028 Date: 0 9 / 0 8 / 2 0 1 4 Qinch Drawing Drawing Type: Construction Authorization Scale: . OBlock QN/A F s 5 s ! � I i �i ► I I �l�h' j'3=.j-`�!qtr 5 � �I I I Ib, i I I I 0-1Ll I - I 1-T ___.I Paae 3 of 3 �� 1octi (61 1 �o 4 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health pA� P.O.Box 848/210 Hospital StreetAU CE 2 Mocksville,NC 27028 RecoiVO� (336)753-6780/Fax(336)753-1680 f Application For: ❑ Site Evaluation/improvement Permit ❑ Autho ' tion To Construct(ATC) ❑ Both Type of Application: ❑New System ❑Repair to Existing System xpansion/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. r APPLICANT INFORMATION - Name h n W). (rs Contact Person 33(o- -7 q -3 3 G 3 C� 1 Address 1 -74v -C,, M 0.,,Ie r, T>r . Home Phone T3 E - -7 S I '2 ro to P o City/State/ZIP M o ' I I.c N C. D 22 Business Phone -13( - -7L/ 7 - V L Email W r�1 l;s, 'o h C D M Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged 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.) Owner's Name .7D h r` I D n, P— 1A/ '/I r S e, Phone Number 33 4--7 ` 'l -3 3 3 Owner's Address City/State/Zip l q,CaJ e-, Property Address O o cv .X, City kt J i ( I t , tN L Z-)o 2, Lot Size Z Ar-res Tax PIN# V 7-(�� -ZZrU I Subdivision Name(if arirsi- licable) Section/Lot# V T Directions To Site: r ; J e-,,.) r; da-e Specify Problem Occurring /-1 r o Ai lge (CJD Y✓I r M a kr✓ b e,4t'D1 M IF RESIDENCE FILL OUT THE BOX LO W #People #Bedrooms # ooms Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes ❑No Basement lu %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 ❑Alternative ❑Other Water Supply Type: ❑ County/City Water ❑New Well ❑Exis ' Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?❑ Yes ❑No If yes,what type? This is to certify that the information provided on tlis 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 housfacility 1 c tion,.proposed well location and the location of any other amenities. /11v/—�- Site Revisit Charge Property own s or owner's legal representative signature Date(s): Z Client Notification Date: Date EHS: Sign given ❑Ye No Account# s ❑ Revised 11/06 Invoice# • DAVIE COUNTY HEALTH Dt=t+Atr i mcn IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION /1,1OTE: issued in Compliance with G.S.of North Carolina Chapter 130 Article 13c Sewage Treatment and Disposal Rules(10 NCAC 10A.1934,1968) Permit Number Name n Date —/�1 !N° 5255 Local ll&o doaalq X wt e/V' .t Subdivision Name Lot No. Sec.or Block No. Lot Size House Mobile Home Business Speculation 'r . _ �r No.Bedrooms��No,Baths No.in Family Garbage Disposal YES Q NO 2- Specifications for System-, Auto Dish Washer YES NO 0 Auto Wash Machine YES NO ❑ < v rt ,X ' Type Water Supply � 'This permit Vold if sewage system described-below Is not Installed within 38 months from date of Issue. , 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. or 1:00-1:30 P.M. on day of ccmpletton. Telephone Number.704-63,4--55985, Final Installation Diagram: System Installed by .f ,3 ,s .I i Certificate of Completion Date jEZ_ '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,