510 Danner Rd OPERATION PERMIT or fice use Only
Ty Davie County Health Department *CDP File Number 122185- 1
N S pmt O
t 210 Hospital Street F4-000-00-006-01
P.O. Box 848 County ID Number:
Mocksville NC 27028 Evaluated For: NEW
Phone:336-753-6780 Fax:336-753-1680 Township:
Applicant: Tracy Jordan Property Owner: Donald Joe Danner
Address: 711 Cana Road Address: 941 Tamworth
CRY: Mocksville City: Asheboro
State2ip: NC 27028 State/Zip: NC 27203
Phone#: (336)998-3906 Phone#:
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
Danner Road
Mocksville NC 27025 Directions
Structure: SINGLE FAMILY Hwy 601 N , Right on Danner to property on Right
#of Bedrooms: 4
across from-Vineyard
#of People: 4
*Water Supply: NEW WELL
*IP Issued by. *System Classification/Description:
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by:
SaproliteSystem? OYes ONo
Design Flow: 4 8 0 *Distribution Type: GRAVITY-SERIAL Pump Required?
OYes (DNo
Soil Application Rate: 0 - a 5 *Pre Treatment:
Drain field
r
on Field Sq.ft. *System Type: INFILTRATOR QUICK4 STANDARD
n Lines 4 Installer: Ritchie Bowman
Total Trench Length: 4 8 0 8• Certification#: 4119
Trench Spacing: — 9 Olnches O.C.
.
. Feet O.C. EH S: 2140-Nations,Robert
Trench Width: 3 Oinches
()Feet Date: 0 8 / 0 8 / .20 1 4
Aggregate Depth: inches
Minimum Trench Depth: Inches
Minimum Soil Cover. Inches Approval Status
Maximum Trench Depth: Inches ED proved O Disapproved
Maximum Soil Cover.
Inches
CDP File Number 122185 - 1 Septic Tank County ID Number: F4-000-00-006-01
Manufacturer. Shoaf Lat.
STB: 760
Long:
Gallons:
1000 Installer: Richie Bowman
Date: 0 / 1 4 / x 0 1 4 Certification#: 4119
*EH S: 2140-Nations,Robert
*Filter Brand: POLYLOK Dual PL-122 With Pipe Adapter
ST Marker: El Yes El NO
Date: 0 8 / 0 8 / .2 0 1 4
Reinforced Tank: E] Yes E] NO
Approval Status
1 Piece Tank: ElYes El No El 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
einforced Tank: ❑ Yes ❑ No ❑ Approved❑ Disapproved
1 Piece Tank: ❑ Yes ❑ No
Supply Line
Pipe Size: inch diameter Installer:
Pipe Length: feet Certification#:
*EH S:
*Schedule:
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 0 Yes ❑ No
CDP File Number 122185 - 1 County ID Number. F4-000-00-006-01
Electric Equipment
NEMA 4X Box or Equivalent El Yes El No 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:
Alarm Audible ❑ Yes ❑ NO Approval Status
Alarm Visible ❑ Yes ❑ No ❑ Approved❑ Disapproved
2140-Nations,Robert
*Operation Permit completed by:
Authorized State Agent: Date of Issue: 0 8 / 0 8 / 0 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 TYPE II A. sewage septic system.
Rule .1961 requires that a Type TYPE 11 A. septic system meet the following criteria:
Minimum System Review ByThe 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 homelbusiness 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 ownerand a management entity priorto the
issuance of an Operation Permit for a system required to be maintained bya public or private management entity, unless the
system ownerand certified operator are the same. The contract shall require specific requirements formaintenance and
operation, responsibilities of the ownerand 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.
OHand Drawing Olmport Drawing
**Site Plan/Drawing attached.`*
OPERATION PERMIT 122185 - 1
Davie County Health Department CDP File Number:
210 Hospital Street F4-000-00-006-01
P.O.Box 848
County File Number:
Mocksville NC 27028 Date:
Olnch
Drawing Drawing Type: Operation Permit Scale: , Qslock
ON/A
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' - CONSTRUCTION For office Use only
AUTHORIZATION •CDP File Number 122185-1 "
Davie County Health Department County ID Number:F4-000-00.006-02
fa 210 Hospital Street .� Evaluated For: NEW
3
P.O. Box 848 Township:
Mocksville 27 PERMIT VALID UNTIL:
Phone:336-753-6780 F - 680 0 7 / 3 0 / 2 0 1 8
Applicant: Tracy Jordan Property Owner. Donald Joe Danner
Address: 711 Cana Road Address: 941 Tamworth
CRY: Mocksville ' CRY: Asheboro
State2ip: NC 27028 State2ip: NC 27203
Phone#: (336)998-3906 Phone#:
Property Location & Site Information
r
ad #: Subdivision: Phase: Lot:
oad
e NC 27025 Directions
Structure: SINGLE FAMILY Hwy 601 N , Right on Danner to property on Right across
from Vineyard
#of Bedrooms: 4
#of People: 4
`Water Supply: NEVyfVELL
System Specifications
Minimum Trench Depth: 1 8
(SiteClassification: PSSWIm-iPlacement Inches
Minimum Soil Cover.olite System? QYes QNo Inches
gn Flow: 4 8 0 Maximum Trench Depth: 2 4 Inches
Soil Application Rate: 0 2 5 Maximum Soil Cover: Inches
'System Classif"tion[Description: 'Distribution Type: GRAVITY-SERIAL
TYPE fl A COW. SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
1 0 0 0 Gallons
'Proposed System: 25%REDUCTION 1-Piece: QYes QNo
Pump Required: QYes QNo Q May Be Required
Nitrification Field
Sq. ft. Pump Tank: 1 0 0 0 Gallons
No.Drain Lines 1-Piece: QYes QNo
Total Trench Length: 4 8 0 n GPM—vs-- ft. TDH
Trench Spacing: _ 9 g
Inches O.C. Dosing Volume: Gallons
Feet O.C.
Trench Width: Inches
3 6
8Feet Grease Trap: Gallons
Aggregate Depth: - - -
inches Pre-Treatment: QNSF OTS-1 OTS-II
Septic Tank Installer Grade Level Required: 01011 0111 01V
Page 1 of 3
• CDP File.Number 122185- 1 County ID Number. F4-000-00-006-02
❑ Open Pump System Sheet
Repair System Required:OYes ONo ONo, but has Available Space
rDesign
System Trench Spacing: 9 Inches O.
g Feet O.C..
ification: PS Shallow Placement —
Trench Width: .� Inches
w: 4 8 0 _ 3 6 Feet
SoilAggregate Depth:
Application Rate: 0 - 2 5 .inches
'System Classification/Description: Minimum Trench Depth: 1 $ Inches
TYPE II A-CONV SYSTEM(SINGLE-FAMILY OR 480 GPO OR LESS) Minimum Soil Cover. Inches
Maximum Trench Depth: 2 4
*Proposed System: Inches
Maximum Soil Cover:
Nitrification Field Inches
Sq.ft.
No. Drain Lines 'Distribution Type: GRAVITY SERIAL
Total Trench Length: 4 8 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 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 forwastewater 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 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 penult 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,rotes.and permit conditions regarding system location,Installation,operation,maintenance,monitoring,reporting and repair
(1938(b)).
ApplicantlLegal Reps.Signature Required? Oyes ONO
Applicant/Legal Reps. Signature- Date:_
'Issued By: 2244-Daywalt.Andrew Date of Issue: 0 7 3 0 2 0 1 3
Authorized State Agent: mi Malfunction Log OYes
OHand Drawing Oimport Drawing TotalTime:(HH:1411)
**Site Plan/Drawing attached.** 0 10 0 Lunutes
Page 2 of 3 Hours_
j S-8-CKS issued-new
CONSTRUCTION AUTHORIZATION
Davie county Health Department CDP File Number. 122185 - 1
210 Hospital Street F4-000-00-006-02
P.O.Box 845 County File Number:
Mocksville NC 27025 Date: 0 7 / 3 0 / 2 0 1 3
Q Inch
Drawtving Drawing Type: Construction'Authorization Scale: . QBlock
QN/A
LIL __1
i
_ SL CL
�
o
j.e_ll
1_ J.
Pane 3 of 3
IMPROVEMENT PERMIT For office UseonlY
"CDP File Number 122185- 1
Davie County Health Department
County ID Number:F4-000-00.006-02
t 210 Hospital Street
y4
P.O.Bax 8�8 Evaluated For: NEW
� _
Mocksville NC 27028 To;unship:
Phone:336-753-6780 Fax:336-753-1680 pER1.11T VALID UJJTIL 7!3012018
'NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit.
Applicant: Tracy Jordan Property owner: Donald Joe Danner
Address: 711 Cana Road Address: 941 Tamworth
City: Mocksville City: Asheboro
State/Zip: NC 27028 State2ip: NC 27203
Phone": (336)998-3906 Phone#:
Property Location & Site Information
Fddress/Road #: Subdivision: Phase: Lot:
Road
le NC 27025 Directions
Structure: SINGLE FAMILY Hwy 601 N , Right on Danner to property on Right
#of Bedrooms: 4 across from Vineyard
#of People: 4
'Water Supply: NEW WELL
System Specifications
nitial System
'Site�TasSiHca an: PS Sha'.tow Ptacement
Minimum Trench Depth: 1 8 Inches
Saprolite System? QYes (')No Maximum Trench Depth: 2 4 Inches
Design Flow: 4 8 0 Septic Tank:
1 0 0 0 Gallons
Soil Application Rate: 0 - 2 5 1-Piece: QYes QNo
Pump Required: ()Yes QNo Oviay Be Required
*System Classification/Description:
TYPE 11 A.COM/SYSTEM(SINGLE-FA LILY OR 480 GPD OR Pump Tank: Gallons
LESS)
'Proposed System: 25',bREDUCT1oN 1-Piece: QYes QNo
Repair System Required:OYes ONO ONo, but has Available Space
C
epair System
Classification: PSShatimmPlacement Minimum Trench Depth: 1 8 Inches
Application Rater 0 - 2 5 Maximum Trench Depth: 2 4 Inches
u
'System Classification/Description: Pump Required: QYes ()No Q htay be Required
TYPE It A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR
LESS)
'Proposed System: 2641 REDUCTION
Page 1 of 3
'CDP File Number 122185- 1 County ID Number. 174-000-00-006-02
*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 of this permit bythe 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.
The Improvement Permit shad be valid for 5 years from date of issue with a site plan(means a drawing not necessarily drawn to
SitePlanstate that shows the existing and proposed property lines with dimensions,the location of the facility and appurtenances,the
sire for the proposed Wastewater system,and the location of water supplies and surface waters).
Plat The Improvement Permit shad be valid without expiration with plat(means a property surveyed prepared by a registered land
surveyor,drawn to a scale of one Inch equals no morethan 60 feet,that Includes:the specific location of the proposed facility
O 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 plat that 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(NCGS 130A-335(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)).
ApplicantlLegal Reps. Signature Required? Oyes ONO
Applicant/Legal Reps. Signature' Date: /
*Issued By: 2244-OaywaltAndrew Date of Issue: 0 7 / 3 0 / 2 0 1 3
Authorized State Agent: M OValid without Expiration?
0Create CA.
OHand Drawing Olmport Drawing
**Site Plan/Drawing attached.** TotalTime:(H1-113M)
0 1 Hours_ 0 0 minutes
Page 2 of 3
Activfty Code: S4-IP'S isstxd:new,valid for 60 mos.
_ IMPROVEMENT PERMIT
Davie County Health Department CDP File Number: 122185- 1
210 Hospital Street F4-000-00-006-02
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: /
Olnch
Drawing Drawing Type: Improvement Permit Scale: . OBlock
ON/A ft.
L-A—,
1 1
lit, 1-1717
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s
Page 3 of 3
• APPLICATION FOR SITE EVAL-UATIONAMPROVEMENT PERMIT_ &ATC
Davie County Environmental Health -'44U=ark P.O.Boa 848/210 Hospital Street bf
Mocksville,NC 27028 'L7
(336)753-6780/Fax
(336)753-1680 ,
Application For: L9 Situ aluation/Improvement Permit k"Authorization To Construct(ATC) 6f Both L
Type of Application: vew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IMPORTANT*'*THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION /
Name to be Billed %e p c t/ �jL.d/� /. Contact Person f�
Billing Address - c_ Home Phone
City/StatefZIP /h o r',461- //fC— 2 70�usiness Phone
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Fla ed (
NOTE: A survey plat or site plan must accompany this application. Included:❑Site Plan ❑Plat(to scale)
(Permit is valid for 60 nths with si plan,no expiration with complete plat)
Owner's Name 1Da-1 � ✓` F Phone Number
Owner's Address 1 n. City/Statc&iP
Property Address city_AA7n r "s s-//5 AIC
Lot Size !7.81-5 A"F-s Tax PIN# J 0 7 7 D(o O 0
Subdivision Name(if applicable), .Dq/V%Z-ir ,v,.r Section/Lot#
Directions To Site: 601 ✓ .2
AccQ S fir, n/.e1A e
If the answer to any of the following questions is`yes",supporting docdin7tatio must be attached.
Are there any existing wastewater systems on the site? Yes
Does the site contain jurisdictional wetlands?. ❑Yes
Are there arty easements or right-of-ways on the site? Dyes
Is the site subject to approval by another public agency? Dyes
Will wastewater other than domestic sewage be generated? ❑Yes o
IF RESIDENCE FILL OUT THE BOX BELOW
#People #Bedrooms #Bathrooms Garden Tub/Whirlpool es 701Basement: es ❑No Basement Plumbing: ❑Yes,BiQo
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 Wcil aExisting Well ❑Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve?❑Yes 040
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 permits)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 corners and
locatmgwd flagging or stakipg the houselfacility location,proposed well location and the location of any other amenities.
1161-1i-4 I`)—- , 1- Site Revisit Charge
Property own ,,s or owner's.legal representative signature
Date(s):
Client Notification Date:
Dat6 EHS:
Sign given ❑Yes❑No Account#
Revised 11/06 Invoice#
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` THIS, THE ��DAY OF 'T" L 2011 AND
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' r DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICAN7f INFORMATION PROPERTY INFORMATION
.� 7:j&7ZoQ jL) F4-600 OU-Dlo-0L
916 fie
Vi
14
Water Supply: On-Site Well _ Community Public
Evaluation By: Auger Boring A Pit 1 Cut
FACTORS 1 _ 2 3 : 4 :. .. -5 6 7 .
Landscape position IW2 .r !✓ FS j7c
Slope % v 0 � p o
".HORIZON I DEPTH -M 6020 o
Texture group -
Consistence
Structure (�
Mineralogy . i
i
HORIZON H DEPTH - .. .-
Texture group
Consistence '
StructureA& Flat AR
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence ;
Structure -
Mineralogy
SOIL WETNESS GN i
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE - = I -
SITE CLASSIFICATION: EVALUATION BY: AxhApiz bat
LONG-TERM ACCEPTANCE RATE: 625'
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
CONSISTEN
y
Moist
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
1Votes �.
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)
ITAR -Irmo-term nrrentnnrP rate-oat/tau/ft7 rnrTr%nC/AC m__:__�.
no M
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