593 Gladstone RdApplicant: Clayton Homes/Scott Smith
Address: 828 Piedmont Drive
CRY: Lexington
State2ip: NC 27292
Phone #: (336) 782-1647
Pro
i
Address/Road :J�`�3
Gladstone RO
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 4
# of People:
'Water Supply: PUBLIC
*IP Issued by. 2140 -Nations, Robert
*CA issued by: 2140 -Nations, Robert
Design Flow: 4 8 0
Soil Application Rate: 0 3
Nitrification Field
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Aggregate Depth:
ierty Locatio
Subdivision:
'CDP File Number 138827-1
L40-000-0025
County ID Number:
Evaluated For: NEW
Township:
Property Owner: Ronald Howell
Address:
City:
State/Zip:
Ph�
Phase: Lot:
Directions
Hwy 601 South, right on gladstone Rd about 1 2/10
mile on left.
'System Classification/Description:
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
Saprolite System? O Yes O No
'Distribution Type: N/A Pump Required?
OYes ONo
*Pre -Treatment:
Drain field
1 6 0 0 Sq. ft.
4 0 0 It.
Qlnches O.C.
— 9 Feet O.C.
Inches
3 Feet
6 inches
Minimum Trench Depth: 3
6
Inches
OPERATION PERMIT
tQ
'
Davie County Health Department
210 Hospital Street
P.O. Box 848
y
Mocksville NC 27028
Inches
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Clayton Homes/Scott Smith
Address: 828 Piedmont Drive
CRY: Lexington
State2ip: NC 27292
Phone #: (336) 782-1647
Pro
i
Address/Road :J�`�3
Gladstone RO
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 4
# of People:
'Water Supply: PUBLIC
*IP Issued by. 2140 -Nations, Robert
*CA issued by: 2140 -Nations, Robert
Design Flow: 4 8 0
Soil Application Rate: 0 3
Nitrification Field
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Aggregate Depth:
ierty Locatio
Subdivision:
'CDP File Number 138827-1
L40-000-0025
County ID Number:
Evaluated For: NEW
Township:
Property Owner: Ronald Howell
Address:
City:
State/Zip:
Ph�
Phase: Lot:
Directions
Hwy 601 South, right on gladstone Rd about 1 2/10
mile on left.
'System Classification/Description:
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
Saprolite System? O Yes O No
'Distribution Type: N/A Pump Required?
OYes ONo
*Pre -Treatment:
Drain field
1 6 0 0 Sq. ft.
4 0 0 It.
Qlnches O.C.
— 9 Feet O.C.
Inches
3 Feet
6 inches
Minimum Trench Depth: 3
6
Inches
Minimum Soil Cover. a
4
Inches
Maximum Trench Depth: 3
6
Inches
M ximum Soil Cover: a
4
Inches
*System Type:
Installer: Aqua Drill - Billy Clayton
Certification #:
*EH S: 2140 - Nations, Robert
Date: 0 8/ 2 0/.2 0 1 4
Approval Status
❑ Approved ❑ Disapproved
CDP File Number 138827 - 1
Manufacturer. Shoaf
STB: 760
Gallons: 1000
Date:
05/
❑
1 1/.2
0 1 4
*Filter Brand:
POLYLOK
Dual PL -122 With Pipe Adapter
ST Marker:
❑
Yes
❑
NO
nforced Tank:
❑
Yes
❑
No
1 Piece Tank:
❑
Yes
❑
No
County ID Number: L40-000-0025
c ianK
Lat. -
Long: -
Installer: Aqua Drill -Billy Clayton
Certification #:
*EHS: 2140- Nations, Robert
Date: 0 8/ 2 0 / 2 0 1 4
Approval Status
El Approved ❑ Disapproved
Pump Tank
Manufacturer. Installer:
PT: Certification #:
Gallons: *EHS:
Date: /
Riser Sealed ❑ Yes
Riser Height: ❑ Yes
einforced Tank: ❑ Yes
1 Piece Tank: ❑ Yes
r5
❑
No
❑
NO (Min.6 in.)
❑
No
❑
No
Pipe Size: inch diameter
Pipe Length: feet
*Schedule:
Pressure Rated ❑ Yes ❑ NO
approved fittings ❑ Yes ❑ No
Pump Type:
Date:
Approval Status
❑ Approved ❑ Disapproved
uppiy Line
Installer:
Certification 9:
*EHS:
Date:
Approval Status
❑ Approved ❑ Disapproved
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 138827 - 1
MCGUIG CUUMMUnt
County ID Number: L40-000-0025
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:
Approval Status
Alarm Audible
1:1
Yes
El
No
ElApproved ❑ Disapproved
Alarm Visible
❑
Yes
❑
No
2140 - Nations, Robert
*Operation Permit completed by:
Authorized State Agent: _ _ Date of Issue: 0 8 / 2 0 / a 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 Il A. sewage septic system.
Rule .1961 requires that a Type TYPE ll A. septic system meet the following criteria:
Minimum System Review By The Local Health Department: N/A
Management Entity: OWNER
Minimum System Inspectioni'Maintenance Frequency By Certified Operator:
N/A
Reporting Frequency By Certified Operator: N/A
Rule .1961 requires that a Type IV and V septic systems designed for a home/business owner must maintain a valid contract
with a public management entity with a certified operator or a private certified operator forthe life of the septic system.
Rule .1961 requires that Type VI septic systems designed fora homelbusiness 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 priorto 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 foras 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.
Oc Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT 138827-1
Davie County Health Department CDP File Number:
210 Hospital Street
County File Number: L40-000-0025
P.O. Box 848
Mocksville NC 27028 Date:
Olnch
Drawing Drawing Type: Operation Permit Scale: , OBlock
ON/A
o
L7
Lf
A
CONSTRUCTION
AUTHORIZATION
Davie County Health Department
V wMk
210 Hospital Street
P.O. Box 848
For Office Use Only
*CDP File Number 138827-1
County ID Number: L40-000-0025
Evaluated For: NEW
Township: J
Mocksvllle NC 27028 PERMIT VALID UNTIL:
Phone: 336-753-6780 Fax: 336-753-1680 0 6/ a 3/.1 0 1 9
Applicant: Clayton Homes/Scott Smith
Address: 828 Piedmont Drive
City: Lexington
State/Zip: NC 27292
Phone #: (336) 782-1647
Address/Road Subdivision:
Gladstone Road
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 4
# of People:
*Water Supply: PUBLIC
'Site Classification: Provisionally Suitable
Saprolite System? O Yes X No
Design Flow: 4 8 0
Soil Application Rate: 0 3
Property Owner: Ronald Howell
Address:
City:
State/Zip:
Phone #:
Phase: Lot:
Directions
Hwy 601 South, right on gladstone Rd about 12/10 mile
on left.
Minimum Trench Depth:
a
4
Inches
Minimum Soil Cover:
1
a
Inches
Maximum Trench Depth:
3
6
Inches
Maximum Soil Cover:
a
4
Inches
*System Classification/Description: *Distribution Type:
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
*Proposed System: 25% REDUCTION
Nitrification Field
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Aggregate Depth:
1 6 0 0 Sq. ft.
Septic Tank. 1 0 0 0
Gallons
1 -Piece: QYes ®No
Pump Required: Q Yes ®No Q May Be Required
Pump Tank: Gallons
4 1 -Piece: QYes QNo
4 0 0 ft. GPM --vs-- ft. TDH
9 Q Inches O.C.
O Feet O.C. Dosing Volume: _ Gallons
3 Q Inches
® Feet Grease Trap: Gallons
inches Pre -Treatment: O NSF OTS -1 OTS -II /
Septic Tank Installer Grade Level Required: O 1 011 0111 01V
Page 1 of 3
CDP File Number 138827 - 1 County ID Number: L40-000-0025
❑ Open Pump System Sheet
%& T es ONO V Ivo, Dui nas myallame apace
/Repair System
*Site Classification: Provisionally Suitable
Design Flow: 4 8 0
Soil Application Rate: 0 3
*System Classification/Description:
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR
LESS)
*Proposed System: 25% REDUCTION
Nitrification Field 1 6 0 0
Sq. ft.
No. Drain Lines 4
Total Trench Length: 4 0 0 ft,
Trench Spacing: O Inches O.
O Feet O.C.
Trench Width: O Inches
O Feet
Aggregate Depth:
inches
Minimum Trench Depth: a 4 Inches
Minimum Soil Cover:
Inches
Maximum Trench Depth: 3 6
Inches
Maximum Soil Cover:
Inches
*Distribution Type: GRAVITY -SERIAL
Pump Required: OYes ®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. Rem`�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. Characters
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 130A336(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? Oyes ONO
Applicant/Legal Reps. Signature: Date:
*Issued By: 2140 - Nations, Robert Date of Issue: 0 6 / a 3 / a 0 1 4
Authorized State Agent: e:v� Malfunction Log Oyes
® Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
• 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: L40-000-0025
Date: 06 /a3/.1014
O Inch
Scale: O Block
O N/A
Page 3 of 3
Pi P2
1 6
Ao
l
It
O
4
j
f
lb
-
I
Q
CA
Q Al
I
Page 3 of 3
Pi P2
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street CDP File Number:
P.O. Box 848 L40-000-0025
Mocksville NC 27028
County File Number:
Date:.0A/ a 3/ a 0 14
Click below to import an image from an external location: Drawing Type: Construction Authorization
Page 3 of 3
P1 P2
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Environmental Health PAID
P.O. Bos 848/210 Hospital Street ,
/ pMocksville, NC 27028
I .�
al � J ��' I �"
�„�,�„�,,,�._ (336)753-6780/ Faa (336) 753-1680 �1�dt�d
Application For: ❑ Site �'aluation/lmprovement Permit ❑ Authorization To Construct(ATC) V, Both :±p
Type of Application:, Blew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IMPORTANT"* THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed c.4 Contact Person 5 L atk- '91-4a,
Billing Address 1 1 "3 F -46S VG W 0 r- Home Phone
City/State/ZIP f kar-Ks ..1 - M . t— --b 10 -1. b Business Phone 3 3 to - -4 'b a ' t li 4'+
Name on Permit/ATC if Different than Above_CI 4
Mailing Address 16:2rp t?<r
-
•L 272 -0 -
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?
0 Yes t11�`<-
Does the site contain jurisdictional wetlands?
❑Yes C�No
k.
Are there any easements or right-of-ways on the site?
Oyes
Is the site subject to approval by another public agency?
❑Yes glNo
Will wastewater other than domestic sewage be generated?
❑Yes 1?fNo
IF RESIDENCE FILL OUT THE BOX BELOW
# People � # Bedrooms 4 # Bathrooms Garden Tub/Whirlpool Dyes
Basement:❑Yeses Basement Plumbing: Dyes es
IF NON-RFCIDENCE 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: VCbriventional ❑Accepted ❑Innovative ❑Alternative .❑Other
Water Supply Type: 0 County/City Water ❑ New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? 13 Yes CTNo
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 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 corners and
l:oscating and pzjng r staking the house/facility location, proposed well location and the location of any other amenities. /1
Property owner's or owner's legal representative signature Site Revisit Charge
5 ' 2'2 i 1 `-k Client Notification Date: � r
Date EHS: V I
Sign given Dyes ❑No Account # q
Revised 11/06 Invoice #
AZ0��p
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
APPLICANT INFORMATION
Account #: 13'S37,7
Billed To:-ge0*1 Mi4h
Reference Name:
Proposed Facility:
PROPERTY INFORMATION
Tax PIN/EH #: L-UdU-C�2�
Subdivision Info:
Location/Address: 0 adIskn
Property Size:/6 Date Evaluated: — a -�>
Water Supply:
On -Site Well
Community
i
Public
Evaluation By:
Auger Boring
Pit
Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
L �-
Slope %
1
HORIZON I DEPTH
Texture group
C C
Consistence
D 50r
Structure
Mineralogy
HORIZON II DEPTH
Texture group.
4f G S
Consistence
Structure
C
Mineralogyt
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE: t
�1 ►7�?'G�:M
EVALUATION BY: oV 1
OTHER(S) PRESENT:
LEGEND j..
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
lu M,_
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
1:1, 2:1, Mixed
Notes
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)
LTAR - Lona -term accentance rate - ual/dav/ft2
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PAN
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Printed -May 29, 2014
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