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992 Daniel Rd CONSTRUCTION . For office Use Only AUTHORIZATION *CDP File Number 138714-1 °"•- Davie County Health Department_ tY P County ID Number. f 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 7 / 0 1 / a 0 1 9 Applicant: Armando Dominquez Rocha Property Owner. Armando Dominquez Rocha Address: 992 Daniel Road Address: 992 Daniel Road City: Mocksville City: Mocksville State2ip: NC 27028 State/Zip: NC 27028 Phone#: (336)917-9563 Phone#: (336)917-9563 Property Location & Site Information FAddress/Road#: Subdivision: Daniel West Phase: Lot: oad NC 27028 Directions Structure: SINGLE FAMILY Hwy 601 South right;Qn Gladstone Rd. right on Daniel Rd 6th on right #of Bedrooms: 3 #of People: *Water Supply: PUBLIC System Specifications Minimum Trench Depth: a 4 Site Classification: Provisionally Inches Saprolite System? 0Yes (K No Minimum Soil Cover. 1 a Inches Design Flow: 2 4 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 . 2 7 5 Maximum Soil Cover. a 4 Inches *System Classification/Description: *Distribution Type: GRAVITY-SERIAL 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: 0 Yes ®No Pump Required: O Yes ®No O May Be Required Nitrification Field 8 7 Sq.ft. Pump Tank: Gallons No. Drain Lines 1-Piece: 0Yes 0 N Total Trench Length: of 1 8 GPM—vs— ft. TDH Trench Spacing: Inches O.C. gFeet O.C. Dosing Volume: Gallons Trench Width: 3 Inches Feet Grease Trap: Gallons Aggregate Depth: inches Pre-Treatment: O NSF OTS-I O TS-II Septic Tank Installer Grade Level Required: 01011 O 111 O IV Page 1 of 3 Int`. g \P C_rry L l�- J CDP File Number 138714 -1 County ID Number. ❑ Open Pump System Sheet Repair System Required:0 Yes O No O No, but has Available Space Repair System Trench Spacing: 9 Inches O. . *Site Classification: Provisionally Suitable — Feet O.C. Trench Width: 3 Inches Design Flow: 6 0 0 __ Feet Soil Application Rate: 0 . a75 Aggregate Depth: inches u *System Classification/Description: Minimum Trench Depth: a 4 Inches TYPE III A.CONV SYSTEM>480 GPD(EXCLUDING SFD) Minimum Soil Cover. 1 e2 Inches *Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Maximum Soil Cover. a 4 Nitrification Field a 1 8 1 Inches Sq.ft. No. Drain Lines 7 *Distribution Type: GRAVITY-PARALLEL(eq.d-box) Total Trench Length: 5 4 rJ ft. Pump Required: Oyes ®No OMay Be Required Pre-Treatment: O NSF OTS-I OTS-II *Site Modifications Chaireclave No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. Remaining 750 *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. R�� add 2 bedrooms and one bath to rear of home and attach to a new 2 bedroom septic system.Add a new deck to the front of the house. 1870 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 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 invalid,and may be suspended or revoked(.1937(8)).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 O No Applicant/Legal Reps. Signature* Date: *Issued By: 2140-Nations,Robert Date of Issue: 0 7 0 1 / a 0 1 4 Authorized State Agent: L4 _ Malfunction Log Oyes ®Hand Drawing O Import Drawing *Site Plan/Drawing attached.** Page 2 of 3 LA ,ot C7 C � 5 � 30 -7 3� _.CONSTRUCTION For Office use Only AUTHORIZATIOW 'CDP File Number 138714- 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 7 / 0 1 / 2 0 1 9 Applicant: Armando Dominquez Rocha Property Owner: Armando Dominquez Rocha Address: 992 Daniel Road Address: 992 Daniel Road City: Mocksville City: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 Phone::: (336)917-9563 (336)917-9563 Phone _j Property Location & Site Information Address/Road Subdivision: Daniel West Phase: Lot: 992 Daniel Road Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 601 South right on Gladstone Rd. right on Daniel Rd of Bedrooms 3 6th on right TM of People: 'Water Supply: PUBLIC System Specifications Irtinimum Trench Depth: a 4 Site Classification: Provisionally Suitable Inches Sa rolite System? Minimum Soil Cover. p y OYes QNo 1 a Inches Design Flow: 2 4 0 l4aximum Trench Depth: 3 6 Inches Soil Application Rate: 0 . a 7 5 10aximum Soil Cover: a 4 Inches 'System Classification/Description: 'Distribution Type: GRAVITY-SERIAL TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons 'Proposed System: 25%REDUCTION 1-Piece: OYes QNo Pump Required: OYes ONo Olwtay Be Required Nitrification Field 8 7 a Sq. ft. Pump Tank: Gallons No. Drain Lines 1-Piece: OYes ONo Total Trench Length: a 1 8 ft GPIA—vs-- ft. TDH Trench Spacing: _ 9 Inches O.C. Dosing Volume: _ Gallons 8Feet O.C. g Trench Width: 3 Olnches OFeet Grease Trap: Gallons Aggregate Depth: inches Pre-Treatment: ONSF OTS-1 OTS-II Septic Tank Installer Grade Level Required: OI OII OIII OIV Pagel of 3 CDP File Number. 138714 - 1 County ID Number: • ❑ Open Pump System Sheet Repair System Required:OYes ONO ONo, but has Available Space rDesign System Trench Spacing: Inches O.C. ification: Provisionally Suitable — 9 Feet O.C. Trench Width: Q Inches w: 6 0 0 _ 3 o Feet Soil Application Rate: la 075 Aggregate Depth: inches .� tvtinimum Trench Depth: a 4 Inches 'System Classification/Description: TYPE III A.CONV SYSTEM>480 GPD(EXCLUDING SFD) twtinimum Soil Cover. 1 a Inches 'Proposed System: 25%REDUCTION Llaximum Trench Depth: 3 6 Inches Maximum Soil Cover: N itrification Field .2 1 8 1 Sq. ft. a 4 Inches No. Drain Lines *Distribution Type: GRAVITY-PARALLEL(eq.d-box) Total Trench Length: 5 4 5 ft. Pump Required: Oyes ()No Otitay Be Required Pre-Treatment: ONSF OTS-1 OTS-ll '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. add 2 bedrooms and one bath to rear of home and attach to a new 2 bedroom septic system.Add a new deck to the front of the house. f This Authorization for Wastewater System Construction shall bevalid for a 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 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)). ApplicanULegal Reps. Signature Required? Oyes ONO ApplicanULegal Reps. Signature: __ _Date: Issued By: 2140-Nations,Robert Date of Issue: 0 7 / 0 1 / .2 0 1 4 Authorized State Agent: �� J Malfunction Log Oyes V Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number: 138714 - 1 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: 0 7 / 0 1 / 2 0 1 4 Q Inch Drawing Drawing Type: Construction Authorization Scale: . QBlock ON/A ate, ��.� � ba1ce s 44 r .>' JU a _ C/ 4u / � a V - r b� Aa `o Paae 3 of 3 HEALTH DEPARTMENT RELEASE For Office Use Only *CD.P File Number; 138714 1 Davie County Health Department .- 210 Hospital Street County 1D N.umber -` P.O. Box 848 EXPANSION Evaluated For Mocksville NC 27028 Phone: 336-753-6780 Fax:336-753-1680 PERMIT VALID 0 6 i 2 6 i a 0 1 9 UNTIL: Applicant: Armando Dominquez Rocha Property Owner: Armando Dominquez Rocha Address: 992 Daniel Road Address: 992 Daniel Road City: Mocksville City: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 Phone M (336)917-9563 Phone#: (336)917-9563 Property Location&Site Information Address 992 Daniel Road Subdivision: Daniel West Phase: Lot: Road#Mocksviiie NC 27028 SINGLE FAMILY Township: *Structure: Directions #of Bedrooms: 3 #of People: Hwy 601 South right on Gladstone Rd.right on Daniel Rd 6th on right 'Water supply: PUBLIC Basement: ❑Yes�No Type of Business: Total sq.Footage: No.Of Employees: *Proposed Improvement: Addition 2 bedrooms *Release Conditions R ms ray This permit is only valid with the completion of the septic installation designated below on page 2.Please do not issue a Certificate of 525 Occupancy until an operations permit is completed by this department for this property. This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any.period of time. Applicant/Legal Reps.Signature Required? Oyes ONO Applicant/Legal Reps.Signature: *Date: *Issued By: 7140-Nations,Robert , r *Date of Issue: 0 6 a 2 0 1 4 Authorized State Agent: **Site Plan/Drawing attached.** Hand Drawing O ImportDrawing HEALTH DEPARTMENT RELEASE sw�a Davie County Health Department CDP File Number: 138714- 1 210 Hospital Street P.O.Box 848 County File Number: Mocksvme . NC 27028 Date: 0 6_/ .2 7 / .10 1 4 120 a O Inch Scale: O Block Drawing Type: Health Department Release O NiA c� l r toof a OF L vA 41f w 11 l w �a age o HEALTHDEPARTMENT RELEASE d+� o Davie County Health Department � 210 Hospital Street CDP File Number: 138714 - 1 _ P.O.Box 848 Mocksville NC 27028 County File.Number: Date: ,0.6 / a 7 / a 0 1 4 Drawing Type: Health Department Release Page 2 of 2 Davie County Health Department X18 j ' Environmental Health Section 1, f{_ .41 . R EjVED P.O. Box 848 �. RSC 210 Hospital Street b .`2 Courier# : 09-40-06 Mocksville, NC 27028 Phone:(336)-753-6780 Fax:(336)-753-1680 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Name: 00 /e Phone Number�A All—A15 b; _(Home) Q Mailing Address: "Iq 4 V\1E� d• (Work) Ij%10( c' ([y Email Address: Detailed Directions To Site: VIM(Y\ Y�YW)'ft ', Dn( 7oUi'Y1 • ot, c i„(s6 ry kleayxiej ' on Property Address: C U Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: Type Of Facility:_ pu ( IYeek 4'6fYi' Date System Installed(Month/Date/Year): Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? No If Yes,For How Long? K%wr 2oto Any Known Problems? Yes If Yes,Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: k Number Of Bedrooms:_2Number of People Pool Size: N k Garage Size: Other: Requested By: Date Requested: S liq Ito 14 (Signature) For Environmental Health Office Use Only Approved Disapproved / /,, ents: 1Pn1V 1/4 �j 1"y I ff D 1 -7 C7� WL AJ - 04 01 ot 4 Environmental Health Specialist Date: 7 *The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee (extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cash - hec Money Order # Amount:$ 150-00, Date: PlAw Paid By: Received By: Account#: g 71 Invoice#: hMi Ij . • �s�i(1e,, A1C v . � RotiJ tap 'r Ycl 2,01 til N 32' �5' DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 'NOTE: 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 1 Date 1 f U:,3 Location Subdivision Name 'QArna& Lot No. Sec.or Block No. Lot Size - House Mobile Home_ I- ` Business Speculation No.Bedrooms No.Baths No.in Family Garbage Disposal YES {] NO x] Specifications for System: Auto Dish Washer YES p NO ] /a 0 Auto Wash Machine YES Ey NO fl �O0 x Type Water Supply 'This permit Void if sewage system described below is not installed within 36 months from date of issue. s ' Improvements permit by L '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:704-634-5985. c` c, Final Installation Diagram: System Installed by , ,- V�lhQ rvle lose, 0.a Certificate of Completion - `�" Date '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. 100 ._..,°Ati«t Rp `"''—�—�30b 1 __„__-_ t 100 t.. mw_97 ,. ag2 2 100 100 ; 107 2825 1851 2748 3863 �e�i 579 �_ " - � r 6747-� 100 s 2 ` 100 7 3 10 r (68) �—_ 100a 95 (1 .1110 131 100 4651 N 100 c-n 563 r 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 Pri nted:J un 02 2014 5 of the use or Inability to use the GIS data provided by this webs"de. r DAVIE COUNTY HEALTH DEPARTMENT J'(i 6 p ,e)1U Environmental Health Section ✓� �� y PO Box 848/210 Hospital Street Mocksville,NC 27028 Phone: (336)751-8760 :i ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) REPLACEMENT❑ REMODELING ❑ RECONNECTION ❑ r Name:_ 3/V�Q cdZ ' Phone Number: (Home) Mailing Address: `f SA A1,14 felfele. !%! ���fc�G �j (Work) Detailed Directions To Site: PropertyAddress: /t: • Q L11 t k Please Fill In The Following Information About The Existing Dwelling. Name System Installed Under: Type Of Dwelling: Date System Installed(Month/Day/Year) - Number Of Bedrooms:Number Of People: Is The Dwelling Currently Vacant? Yes❑ No❑ If Yes,For How Long? Any Known Problems?Yes❑ No❑ If Yes,Explain: Please Fill In The Following Information About The New Dwelling: Type Of Dwelling: �/// bi . ber' TF Bedrooms: Number Of People: )�equested By: /T Date Requested: 0'::] (Signature For Environmental Health Office Use Only Approvedisapproved ❑ r i Comments: Environmental Health Specialist Date "The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee(extended or limited)that the on-site wastewater system will function propei°ly,for any given period of time. Payment: Cash Chet ❑ Money Order❑ # Amountl$ .l Date: l o��� Paid By: Received By: Account #• 6'rsa b. Invoice #• des DAVIE.COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT.-AND CERTIFICATE OF COMPLETION *NOTE: 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 Date Location Subdivision Name O.M Lot No. Sec. or Block No. Lot Size House Mobile Home _ ✓ Business Speculation No. Bedrooms �' No. Baths No. in Family _ Garbage Disposal YES p NO p Specifications for System: Auto Dish Washer YES p NO �0'005 ,,,� �� � Auto Wash Machine YES NO x � Type Water Supply *This permit Void if sewage system described below is not installed within 36 months from date of issue. t i a 1` ! 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 completion. Telephone Number: 704-63^4-5985. Final Installation Diagram: System Installed by r — --------- -�:: ri rr( Certificate of Completion Date J ��_- #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. •� sr APPLICATION-FOR SITE•EVALUATION/IMPROVEMENTS PERMIT s Davie County Health Department MaR Environmental Health Section �Q P. 0. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 9 I5 -5"? �' ��`/•"<.i- 1. Permit Requested By - Business Phone 2. Address 5 C 3. Property Owner if Different than Above _ Address 4..Permit To: a) Install Alter Repair b) Privy Conventional Other Type Ground Absorption 3 c) Sub-Division Qq_uV rL (,&5- Sec. —Lot No. 5. System used to serve what type facility: House Mobile Homed Business Industry Other b) Number of people '46-cat 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions /�� V G11, Bed Rooms—Bath Rooms ,/ Vi Den w/Closet b) If Business, Industry or Other, State: Number of persons served What type business, etc. Estimate amount of waste daily (24'hours) 7. Number and type of water-using fixtures: commodes urinals garbage disposal lavatory showers washing machine dishwasher sinks 8. a) Type water supply: Public ✓ Private Community b) Has the water supply system been approved? Yes_jZNo 9. a) Property Dimensions b) Land area designated to building site c) Sewage Disposal Contractor 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? What type? This is to certify that the information is correct to the best of my knowledge. Date Owner Signatur OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: DCHD(6-82) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 - SOIL/SITE EVALUATION Name - CSV Date y Address Lot Size 440-11 � FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S PV PS PS PS U U U U 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) (P PS PS PS U U. U U 3) Soil Structure (12-36 in.) S S S Clayey Soils PS PS PS U U U 4) Soil Depth (inches) S^ S S S PS PS PS U U U U 5) Soil Drainage: Internal S S S pg PS PS PS U U U External S S S S PS PS PS 4:1 U U U U 6) Restrictive Horizons 7) Available Space S. S S PS' PS PS PS U U U U 8) Other (Specify) S S S S PS PS PS PS U U U U 9) Site Classification AQ5— U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: Described by Title l�fJ Date SITE DIAGRAM DCHD(6-82)