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331 Feed Mill RdOPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Tommy Lee Cope Address: 331 Feed Mill Rd City Advance State/Lip: NC 27006 Phone #: Address/Road #: Subdivision: 331 Feed Mill Rd Advance NC 27006 Structure: SINGLE FAMILY # of Bedrooms: # of People: 'Water Supply: NIA 'IP Issued by. "CA issued by: 2140 - Nations, Robert Design Flow: a 4 0 Soil Application Rate: 0 2 7 5 rt -or uttice use unto "CDP File Number 187720-1 G8 -000-00-047-A County ID Number. Evaluated For. EXISTING Township: / Property owner. Tommy Lee Cope Address: 331 Feed Mill Rd City: Advance State/Zip: NC Phone #: 27006 Phase: Lot: Directions Hwy 158, Right on Hwy 801, cross RR Tracks Feed Mill Rd on right to the end 'System Classification/Description: TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Saprolite System? 0Yes $,F)No *Distribution Type: GRAVITY- PARALLEL (eq. d -box) Pump Required? QYes QNo 'Pre Treatment: Drain field Nitrification Field 1 3 0 9 Sq. ft. No. Drain Lines 1 Total Trench Length: 2 1 8 ft. Trench Spacing: 9 Olnches O.C. _ r Feet O.C. Trench Width: 3 Inches Feet Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4 Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: 2 4 Inches 'System Type: INFILTRATOR QUICK 4 STANDARD Installer: Brian McDaniel Certification #: 'EH S: 2140 - Nations, Robert Date: 0 1/ 2 8/ 2 0 1 5 Approval Status E Approved Disapproved a CDP Fite Number 187720 ` I Inches / Septic Tank County ID Number: G8 -000-00-047-A Yes ❑ No RiserHeight: ❑ Yes Lat. - Manufacturer. Yes ❑ No 1 Piece Tank: ❑ Yes ❑ No PVC Unions ❑ Yes ❑ No Long: , STB: No Anti -siphon Hole ❑ Yes ❑ No Installer: Gallons: Certification #: Date: J J *EHS: 'Filter Brand: ST Marker: ❑ Yes ❑ No Date: J / Reinforced Tank: ❑ Yes ❑ No Approval Status Approved ❑ Disapproved 1 Piece Tank: ❑Yes ❑ No.© Pump Tank Manufacturer, installer. PT: Certification #: Gallons: *EHS: Date: / Inches / RiserSealed ❑ Yes ❑ No RiserHeight: ❑ Yes ❑ No (Min.6 in.) nforced Tank: ❑ Yes ❑ No 1 Piece Tank: ❑ Yes ❑ No Date: Approval Status ❑ Approved ❑ Disapproved Supply Line Pipe Size: inch diameter Installer: Pipe Length: feet Certification #: *EHS: *Schedule: Pressure Rated ❑ Yes ❑ No Date: approved fittings ❑ Yes ❑ No Approval Status ❑ Approved f Disapproved Pump Type: Installer: Dosing Volume: — ,Sal Certification #: Draw Down: Inches *Chau: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check -valve ❑ Yes ❑ No PVC Unions ❑ Yes ❑ No Vent Hale ❑ Yes ❑ No Anti -siphon Hole ❑ Yes ❑ No *EH S: Date: Approval Status ❑ Approved ❑ Disapproved CDP File Number 187720 -1 Electric E NEMA 4X Box or Equivalent ❑ Yes ❑ No Box 12 inches Above Grade ❑ Yes ❑ No Box Adj.To Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No Pump Manually Operable ❑ Yes ❑ No *Activation Method: Alarm Audible ❑ Yes ❑ No Alarm Visible ❑ Yes ❑ No 2140 - Nations, Robert *Operation Permit completed by: Authorized State Agent% Owner/Applicant Signature: County ID Number: G8 -000.00.047-A Apment Installer: Certification #: *EH S: Date: Approval Status ❑ Approved ❑ Disapproved' Date of Issue: 0 1/ 2 8/ 2 0 1 5 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 it 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: NIA Management Entity: OWNER Minimum System InspectionlMaintenance Frequency ByCertified Operator: NIA Reporting Frequency By Certified Operator: NIA 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 fora home/business owner must maintain a valid contract with a public management entity with a certified operator for the lire 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 fora system required to be maintained bya 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 es 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 JlmportDrawing **Site Plan/Drawing attached.** Drr_.4— OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC CDP File Number: 187720-1 County File Number: G8-ooa-oa-oa*a-A 27028 Date: Q Inch Scale: QSlock = ft. r ,- CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Tommy Lee Cope Address: 331 Feed Mill Rd City: Advance State/Zip: NC Phone #: 11 Address/Road #: 331 Feed Mill R( Advance Structure: # of Bedrooms: # of People: *Water Supply: NC 27006 SINGLE FAMILY N/A 27006 Subdivision: 'Site Classification: Provisionary Suitable Saprolite System? O Yes 631 No Design Flow: a 7 5 For Office Use Only *CDP File Number 187720 - 1 County ID Number: G8 -000-00-047-A Evaluated For: EXISTING Township: PERMIT VALID UNTIL: 01/15/x0.10 Property Owner: Tommy Lee Cope Address: 331 Feed Mill Rd City: Advance State/Zip: NC hone #: & Site Informatio 27006 Phase: Lot: Directions Hwy 158, Right on Hwy 801, cross RR Tracks Feed Mill Rd on right to the end Saecifications Minimum Trench Depth: 2 4 Inches \ Minimum Soil Cover: 1 a Inches Maximum Trench Depth: 3 6 Inches Maximum S R C GPM --vs— ft. TDH Soil Application Rate: of over. a 4 3 6 0 Inches *System Classification/Description: *Distribution Type: GRAVITY - PARALLEL (eq. d -box) TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: Gallons *Proposed System: 25% REDUCTION 1 -Piece: O Yes O No Pump Required: O Yes ®No O May Be Required Nitrification Field 1 3 0 9 Sq. ft. Pump Tank: Gallons No. Drain Lines 3 1 -Piece: OYes ONo Total Trench Length: 3 0 7 ft GPM --vs— ft. TDH Trench Spacing: —9 ® O Inches O.C. Feet O.C. Dosing Volume: Gallons Trench Width: 3 Olnches ®Feet — Grease Trap: Gallons Aggregate Depth: inches Pre -Treatment: O NSF OTS -1 OTS -II Septic Tank Installer Grade Level Required: 01011 O III O IV / Page 1 of 3 CDP File Number 187720 - 1 County ID Number: G8-OOb-00-047-A ❑ Open Pump System Sheet uired: ®Yes O No O No, but has Available Space *Site Classification: Provisionally Suitable Design Flow: 3 6 0 Soil Application Rate: 0 a 7 5 *System Classification/Description: TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System: 25% REDUCTION Nitrification Field 1 3 0 9 Sq. ft. No. Drain Lines 3 Total Trench Length: 3 a ft. Trench Spacing: 9 O Inches 0. — ® Feet O.C. Trench Width: — 3Inches 817eet Aggregate Depth: inches Minimum Trench Depth: a 4 Inches Minimum Soil Cover: 1 a Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: a 4 Inches *Distribution Type: GRAVITY - PARALLEL (eq. d -box) Pump Required: OYes ®No OMay Be Required Pre -Treatment: O NSF 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. Remaa��9 750 *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. Reme�`�g 2000 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(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? O Yes O No Applicant/Legal Reps. Signature, Date: / *Issued By: 2140 - Nations, Robert Date of Issue: 0 1/ 1 5/ 2 0 1 5 Authorized State Agent: �� ' ialfunction Log OYes Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 1 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 CDP File Number: 187720 - 1 County File Number: G8 -000-00-047-A Date:.0.1./ 15 / .2 0 15 Click below to import an image from an external location: Drawing Type: Construction Authorization Page 3 of 3 P1 P2 �r 0 DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUES APPLICATION IP/ATC OSWW REPAIR Name U F11 /i I U h LX) Address -�?31 Mailing Address (if different from above) Email Address: Subdivision Name Directions kv U I ti v 1 tl�j Date System Type Facility Type Water S � Telephone Number If N Name System Installed Under -L Number Bedrooms Number People Specific Problem Occurring Date Requested f_7-1 h� Info Taken By THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY KNOWLEDGE, AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED FROM THIS APPLICATION. Signature of owner or Authorized Agent Initial Fee Date RENS Revisit Charge Date Reason Revised 2-2011 \ , DAVIE COUNTY--tWIRONMENTAL HEALTH SERVICE REQUEST APPLICATION IP/ATC OSWW REPAIR Name ' i l )� d— Telephone Number Address 3 I R L.I Mailing Address (if different from above) Vu Email Address: y - 66 ) SubdivisionName Lot /Z& 11?� Directions h Cl u (� 0 &J j11AAj 0 Date System Installed Name System Installed Under t Type Facility 'Number Bedrooms Number People Served Type Water Supply Specific Problem Occurring Date Requested �' Info Taken By �� THIS IS TO CERTIFY THA THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY KNOWLEDGE, AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED FROM THIS APPLICATION. Signature of owner or Authorized Agent Initial Fee Date REHS Revisit Charge Date Reason Revised 2-2011