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943 Fork Bixby Rd (2)I 1 OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-763-1680 Applicant: Brian Jones Address: 896 Fork Bixby Rd City: Advance State2ip: NC 27006 Phone #: (336) 785-8975 t-orumce use unly "CDP File Number 187812.1 17-OOMO-051 County ID Number. Evaluated For. NEW Township:. Property Owner: Jerry JonB8 Address: 943 Fork Bixby Rd City. Advance State2ip: NC 'Phone #: (336) 817-3622 27006 Pro a Location & Site Information dress/Road #: Subdivision: Phase: Lot: Off Fork Bixby Rd r Advance NC 27006 Directions Hwy 64 East left on Fork Bixby Rd. left on driveway Structure: SINGLE FAMILY for 943 Fork Bixby, past Williams Rd. # of Bedrooms: 3 # of People: 'Water Supply: PUBLIC *IP "System Classification/Description: Issued by. 2i4a-fVations,Robert TYPE It A. CONY SYSTEM (SINGLE-FAMILY OR 486 GPD OR LESS) *CA issued by: 2140. Nations, Robert Saprolite System? OYes @ No Design Flow: 3 6 0 'Distribution Type: GRAVITY - PARALLEL (eq. d -box) Pump Required? O Yes O No Soil Application Rate: 0 a 5 *Pre Treatment: Drain field FNIrnifimtion Field 1 4 4 0 Sq. ti• *System Type: BIODIFFUSERARC36 n Lines 6 Installer: -TimAbee Total Trench Length: 3 6 0 ft. Certification #: Trench Spacing: _ , Inches O.C. wo Feet O.C. 'EH S: 2140 - Nations. Robert Trench Width: _ 3 Otnches Feet 1 a/ 1 1/ a 0 1 5 Date: Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4 Inches Approval Status Maximum Trench t)epih 3 6 ® Approved b Disapproved Inches Maximum Soil Cover: a 4 Inches CDP File Number 187812 - '1 Manufacturer. Shoaf STB: 760 Gallons: 1000 County ID Number: 17.000-00.051 ' Sectio Tank Date: 0 g/ 1 8/ a 0 1 5 *Filter Brand: POLYLOK PL -122 With Pipe Adapter ST Marker: ❑ Yes ® No nforced Tank: ❑ Yes ❑ No 1 Piece Tank: ❑ Yes El No Manufacturer. us Gallons: Date: Lat. Long: Installer. TimAbee Certification #: *EH S: 2140- Nations. Robert RiserSeeled ❑ Yes ❑ No RiserHeight: ❑ Yes ❑ No (Min.6 in.) nforced Tank: ❑ Yes ❑ No 1 Piece Tank: ❑ Yes ❑ No r Pipe Size: inch diameter Pipe Length: feet *Schedule: Pressure Rated ❑ Yes ❑ No Approved fittings ❑ Yes ❑ No Installer: Certification #: *EH S: Date: / / Date: Approval Status. Approved ❑ Disapproved J / Pump Type: Installer. / Dosing Volume: — Gal Certification #: Draw Down: Inches *EHS: *Chau: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ NO Check -valve ❑ Yes ❑ No Approval Status PVC Unions ❑ Yes ❑ No ❑ Approved Cl Disapproved Vent Holo ❑ Yes ❑ No Anti -siphon Hole ❑ Yes ❑ No CDP File Number 187812 " 1 County ID Number: I7-000-00.051 Electric Equipment NEMA 4X Box or Equivalent ❑ Yes ❑ 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 ❑ NoAPprovalStatus ❑Approved❑ Disapproved Alarm Visible El Yes E3 No 2140 - Nations, Robert *Operation Permit completed by: Authorized State Agen,•c--��_� �� Date of Issue: 1 2/ 1 1/ 2 0 1 5 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. Sep., and all conditions of the Improvement Permit and Construction Authorization, This property is served by a TYPE 11 A. sewage septic system. Rule .1961 requires that a Type TY'E II A septic system meet the following criteria: Minimum System Review By The Local Health Department: NIA Management Entity: OWNER Minimum System Inspection/Maintenance 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 for a 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 ownerand certified operator are the same. The contract shall require specific requirements formaintenance 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. tt 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 Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC Drawing Drawing Type: Operation Permit CDP File Number: 187812 - 1 County File Number: 17-00o-oo-051 27028 Date: ! / Olnch Scale: OBlock ONIA - - - - - - - - - - - 57 41 -- - ----------- - n'�I ------------ ' I o�� tea` Address/Road #: Off Fork Bixby Rd Advance NC 27006 Structure: SINGLE FAMILY # of Bedrooms: 3 # of People: *Water Supply: PUBLIC Subdivision: Phase: Lot: Directions Hwy 64 East left on Fork Bixby Rd. left on driveway for 943 Fork Bixby, past Williams Rd. /Site CONSTRUCTION For Office Use Only a 4 Inches \Si AUTHORIZATION Provisionally suitable *CDP File Number 187812 - 1 °"•»=`�' Davie Count Health Department Y P County ID Number: 17-000-00-051 210 Hospital Street 1 a Evaluated For: NEW .�,. P.O. Box 848 Township: Design Flow: Mocksville NC 27028 PERMIT VALID UNTIL: Maximum Trench Depth: Phone: 336-753-6780 Fax: 336-753-1680 Soil Application Rate: 0 1/ a 9/ a 0 a 0 Applicant: Brian Jones Property Owner: Jerry Jones Address: 896 Fork Bixby Rd Address: 943 Fork Bixby Rd City: Advance City: Advance State/Zip: NC 27006 State/Zip: NC 27006 \ Phone #: (336) 785-8975 Phone #: (336) 817-3622 Address/Road #: Off Fork Bixby Rd Advance NC 27006 Structure: SINGLE FAMILY # of Bedrooms: 3 # of People: *Water Supply: PUBLIC Subdivision: Phase: Lot: Directions Hwy 64 East left on Fork Bixby Rd. left on driveway for 943 Fork Bixby, past Williams Rd. /Site Minimum Trench Depth: a 4 Inches \Si Classification: Provisionally suitable Minimum Soil Cover: 1 a Sa rolite System? OYes �No 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: GRAVITY - PARALLEL (eq. d -box) 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: O Yes ® No Pump Required: O Yes ®No O May Be Required Nitrification Field 1 4 4 0 Sq. ft. Pump Tank: Gallons No. Drain Lines 3 1 -Piece: OYes ®No Total Trench Length: 3 6 0 GPM --vs-- ft. TDH ft. Trench Spacing: _ g Inches O.C. Feet O.C. Dosing Volume: _ Gallons Trench Width: 3 Inches Feet _ Grease Trap: Gallons Aggregate Depth: inches Pre -Treatment: O NSF OTS -1 OTS -II / Septic Tank Installer Grade Level Required: 01011 O 111 01V Page 1 of 3 CDP File Number 187812 - 1 County ID Number: 17-000-00-051 ' ❑ Open Pump System Sheet Uired:w Yes V Ivo V Ivo, put nab Fivallal)lt: OpdL;t: ,'Repair System *Site Classification: Provisionally Suitable Design Flow: 3 6 0 Soil Application Rate: 0 a a 5 *System Classification/Description: TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System: 25% REDUCTION Nitrification Field 1 4 4 0 Sq. ft. No. Drain Lines 3 Total Trench Length: 3 6 0 ft. Trench Spacing: 9 O Inches O. Feet O.C. Trench Width:— 3 � Inches Feet 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 O No O May Be Required Pre -Treatment: O NSF OTS -I OTS -II *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. Remdnn9 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. Rema'�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 ONO Applicant/Legal Reps. Signature Date: *Issued By: 2140 - Nations, Robert Date of Issue: 0 1 / a 9 / a 0 1 5 Authorized State Agent: Malfunction Log Oyes (9 Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 n CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Drawing Type: Construction Authorization CDP File Number: County File Number: �'-000-00-051 Date: 0 1/� 9/ a 0 1 5 0 Inch Scale: O B�ock = .ft. � N/A _ ___._. _ ------_ _ . - ___ __ ____,I i I � ; � i � ' � ' __� ........... . � ;._— � ........._ . i .............. i ............. .. . I.......... ._..I. _ I . . _. —_ > l.___._ ......... .... � ; � � I � � � � ' i i ' ' � i --- __� . ___ ___ , _�_. ____ . , ... ---. ,..... . . ; ; ; __ _ _. ; _. i , � ; : ; � ! ; � � ' � � _ . ....... . .__..._ , I i I ---. .... -- ---.... � - - --�-- - - ---- - --i ... .... __..---- ... . .----- , i ( E ---�-- -- I . 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I ( ."' : __. __� "" " "" I'_�}- � ._.." __-.'_' __ '_'_' �__r ' ' I "'_ "" "".. I I ....._.. _ _.... _ _ " I I � I � � ( � � � � � ' . i � i � � � j � � .�_ ........ . ......... ...... . .._._ _. . . _ ___'_.. .. __. f � _ ; I f. __.. I I _ I � - , � E I ._ __. �- -- � ._--�---- -- . _ -- - -- - .- -- � _. -- ----!- � � ' � 1 �'' I �� ; i, , , � � � � i � , � , ' ! � i � � _:_...... ___ � __ . --__.__ _. __ -_ _- - -- - .._ . ; :- _ , i � i � i � I. : ( � I � I � ' I I I! � � — ----- __ ___T ----------: ' -- --- -- --- --- � , i ; --- ----- .-- -- -- - ; ' ; I, i i ; ; , i I I , � . ;. , _ � __ i __ _-_ . � � , ;— � __ � � � ' 1-- ---- � � -�- -. ...__ � __ _ __ ; i _–I Page 3 of 3 P1 P2 CONSTRUCTION AUTHORIZATION Davie County Health Department S 210 Hospital Street CDP File Number: (� O. Box 848 (J County File Number: I�-000-oo-os1 Q /y !/ 0 G (A Q u Mocksville NC 27028 l Date: .0.l./.a.9./.a.0.1.5. 00a s � � AS!S Click to import an image from an external location: Drawing Type: Construction Authorization r, 19 Page 3 of 3_ a ` �`j � -hot. 1 P2 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC PAID Davie County Environmental Health RECEIVED P.O. Box 848/210 Hospital Street Date: — 2 Mocksville, NC 27028 Date: 1 7 . /It- (336)753-6780/ Fax (336) 753-1680 Application For: VSite Evaluation/Improvement Permit IKAuthorization To Construct(ATC) ❑ Both Type of Application: )(New System ❑Repair to Existing System ❑Expansion/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. Name to be Billed ( i mAe—s Contact Person' , -RA JyAes Billing Address S q G IVP X S rah kA d Home Phone 33 L— '7'95- !R417.6 City/State/ZIPy,An" IVIG .2-7006 Business Phone Name on Permit/ATC ifDjerent than Above Mailing Address 'a City/State/Zip V. -c a I✓G PROPERTY INFORMATION *Date House/Facility Comers 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 Phone N nber 336' 9 R4 -gqoc Owner's Address l -K City/State/Zip oNG>~ C &I Property Address ,$�,K �, City s/ sue G Lot Size I .ee Tax PIN# -7-0 Subdivision Name(if applicable) Section/Lot# Directions To Site: Q q3 i Y b U If the answer to any of the following questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑ Yeso Does the site contain jurisdictional wetlands? 0Y. !Z40 Are there any easements or right-of-ways on the site? ❑Yes XNo Is the site subject to approval by another public agency? ❑Yes h(No Will wastewater other than domestic sewage be generated? ❑Yes)(No IF RESIDENCE FILL OUT THE BOX BELOW # People -3 # Bedrooms # Bathrooms ;Z. Garden Tub/Whirlpool)(Yes ❑No Basement: ❑Yes rANo Basement Plumbing: ❑Yes YNo 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: Xtonventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type:)(County/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, what type? ;KNo 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 permit(s) 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 comers and I ting and fla ng or staking the house/facility location, proposed well location and the location of any other amenities. pe s or owner's legal representative signature Site Revisit Charge Date(s): " ' _ Client Notification Date: Date EHS: Sign given OYes ONo Account # Revised 11/06 Invoice # C'el -60-0'51 1 -Act c. c? ,t-, i I I Brian Jones Fork Bixby Rd 336 785-8975 Water Supply: Evaluation By: )AVIS COUNTY HEALTH DEPARTM Environmental Health Section Soil/ Site Evaluation PAOPERTY 2 3 5 6 ..7 INFORMATION Slope % I HORIZON I DEPTH i m_ Lr O I Texture group j C Jerry Jones 336 817-3622 1 Acre �I e Well Community f Public Boring Pit Cut FACTORS i 1 2 3 5 6 ..7 Landscape position I L Slope % I HORIZON I DEPTH i m_ Lr O I Texture group j C G Consistence i o 0 Al Structure I Mineralo HORIZON H DEPTH I I Texture group! Consistence i Structure t MineralogyI i HORIZON III DEPTH P Texture group! Consistence i Structure ' I Mineralogy HORIZON IV DEPTH { Texture groupi Consistence I Structure f i Mineralogyi SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE j I CLASSIFICATION 1, i LONG-TERM ACCEPTANCE RATE 0 -1 1 SITE CLASSIFICATION: LONG-TERM ACCEPTANCE REMARKS: T-� RATE: EVALUATI i N BY: u Q , pZ OTHER(S) PRESENT: PP LLandscapC Position R - Ridge S - Shoulder CC - Concave slope CV- Texture L - Linear slope onvex slope LEGEND FS - Foot slope Ni- Nose slope' T - Terrace FP - Floo& plain H'!- Head slope J - oull -Ja11�ll UY 1VQ111 L - LVCLLll VL -. VllL SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C - Clay } f CONSISTENCE Moist VFR - Very friable FR - F able FI - Firm VFI - Very firm EFI - Extremely firm NS - Non sticky SS-.Sligltly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic j Structure SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineralony 1:1, 2:1, Mixed Notes Horizon depth - In inches } i Depth of fill - In inches i Restrictive horizon - Thickness and inches from land surface iprolite - S(suitable), U(unsuitable) 1 wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less oissification - S(suitable), PS(provisionally suitable), U(unsuitable)