193 Hillcrest Dr (2)OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Jeffrey A Jones
Address: PO Box 2012
City: Advance
State0p: NC 27006
Phone #: (336) 577-2794
Address/Road #: Subdivision:
Hillcrest Drive
Advance NC 27006
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
*Water Supply: PUBLIC
*IP Issued by.
*CA issued by: 2140 -Nations, Robert
Design Flow: 3 6 0
Soil Application Rate: 0 a 7 6
Nitrification Field
No. Drain Lines
Total Trench Length
Trench Spacing:
Trench Width:
Aggregate Depth:
rorurnce use Univ
*CDP File Number 201706-1
5870893294
County ID Number.
Evaluated For. EXPANSION
Township. ;
r/P—roperty Owner: Jeffrey A Jones
Address: PO Box 2012
City: Advance
State2ip: NC 27006
Phone #: (336) 577-2794
Phase: Lot: 2
Directions
Hwy 158 right on Hwy 801 left on Hillcrest on the
right behind #195
*System Classification/Description:
TYPE 11 A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
SaproliteSystem? OYes 9)No
*Distribution Type: GRAVITY -SERIAL Pump Required?
0Yes JE)No
*Pre Treatment:
Drain field
1 3 0 9 Sq. ft.
3
a 0 0 ft.
— 9 Inches O.C.
Feet O.C.
Inches
3 Feet
inches
*System Type: INFILTRATOR QUICK 4 STANDARD
Installer: Jamie Bames
Certification #: i018
*EH S: 2140 -Nations, Robert
Date: 0 3/ a 1/ a 0 1 6
Minimum Trench Depth: 3
Minimum Soil Cover. a
6
4
Inches
Inches
�ApprovalMS#atus
Maximum Trench Depth: 3
6.
Inches
CDAppr�ovedCl
Disapproved
Maximum Soil Cover: 2
4
Inches
CDP File Number 201706 - 1
ciectric =uulDmeni
County ID Number: 5870893294
N EMA 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
❑
Na
*Activation Method:
Date:
Alarm Audible
❑
Yes
❑
No
Approval Status
❑Approved ❑ :Disapproved
Alarm Visible
❑
Yes
❑
No
2140 • Nations, Robert
*Operation Permit completed by;
Authorized State Agergo
Owner/Applicant Signature:
Date of Issue: 0 3/ 2 1 / 2 0 1 6
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 II A, sewage septic system.
Rule ,1961 requires that a Type TYPE n A septic system meet the following criteria:
Minimum System Review By The Local Health Department: NIA
_ __ Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency By Certified Operator:
N/A
Reporting Frequency By Certified Operator: NIA
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 entitywdh a certified operator forthe 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 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 as long as the
system is in use, and other requirements for the continued proper performance of the system. Itshalt also be a condilion of
the Operation Permit that subsequent owners of the systems execute such a contract.
QHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
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: Jeffrey A Jones
Address: PO Box 2012
City: Advance
State/Zip: NC 27006
Phone #: (336) 577-2794
/ For Office Use Only
*CDP File Number ` 201706 -1
County. ID, Number: 5870893294
Evaluated For: EXPANSION
Township:
0 3/ 1 1/ a 0 a 1
Property Owner: Jeffrey A Jones
Address:
PO Box 2012
City:
Advance
State/Zip:
NC 27006
Phone #:
(336) 577-2794
Property Location & Site Information
Address/Road #: Subdivision:
Hillcrest Drive
Advance NC 27006
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
*Water Supply: PUBLIC
Phase: Lot: 2
Directions
Hwy 158 right on Hwy 801 left on Hillcrest on the right
behind #195
*Proposed System: 25% REDUCTION
Nitrification Field
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Aggregate Depth:
Up Ic an . Gallons
1 -Piece: O Yes O No
Pump Required: O Yes O No O May Be Required
4 3 6 Sq. ft. Pump Tank: Gallons
1 1-Piece:OYes ONo
1 0 9 ft, GPM --vs— ft. TDH
Inches O.C.
9 Feet O.C. Dosing Volume: _ Gallons
3 2Inches
® Feet Grease Trap: Gallons
inches Pre -Treatment: O NSF OTS -I OTS -11 /
Septic Tank Installer Grade Level Required: 01011 O 111 O IV
Page 1 of 3
Minimum Trench Depth:
a
\
4
Site Classification: Provisionally Suitable
Inches
Minimum Soil Cover:
1
a
Saprolite System? O Yes ® No
Inches
Design Flow: 3 6 0
Maximum Trench Depth:
3
6 Inches
Soil Application Rate: 0. a 7 5
Maximum Soil Cover:
a
4 Inches
*System Classification/Description:
*Distribution Type:
GRAVITY -SERIAL
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
S t. T k'
*Proposed System: 25% REDUCTION
Nitrification Field
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Aggregate Depth:
Up Ic an . Gallons
1 -Piece: O Yes O No
Pump Required: O Yes O No O May Be Required
4 3 6 Sq. ft. Pump Tank: Gallons
1 1-Piece:OYes ONo
1 0 9 ft, GPM --vs— ft. TDH
Inches O.C.
9 Feet O.C. Dosing Volume: _ Gallons
3 2Inches
® Feet Grease Trap: Gallons
inches Pre -Treatment: O NSF OTS -I OTS -11 /
Septic Tank Installer Grade Level Required: 01011 O 111 O IV
Page 1 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department
c
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Construction Authorization
CDP File Number: 201706 - 1
County File Number: 5870893294
Date: 03/ 11/ 2016
O Inch
Scale: O Block
O N/A
Page 3 of 3
P1 P2
' Davie County Health Department
Environmental Health Section -
P.O. Bos 848
<1�9
210 Hospital Street
W
lZ Courier # . 0940-06
Alocksville, NC 27028
Phone: (336) - 753 - 6780 Fax: (336) - 753-1680
ON-SITE WASTEWATER CERTIFICATION _
(Check One) Replacement Remodeling econnection
Name: J Phone Number 11 &o 5-?') �)-Yq V(Home)
Mailing Address: (Work)
Detailed Directions To Site: -e L' -!�AC I % b So ✓ F14 - ,2 iL N ! G G E 7 D N
S 1 1 rl A/)' b)0 AAf %,
Property Address: fa 5- -" Ll ZL r P_ f T - - Z L o 4-r
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: Type Of Facility:
Date System Installed (Month/Date/Year): Number Of Bedrooms: 3 Number OfPeople: q x .5-"
Is The Facility Currently Vacant? 'e No If Yes, For How Long?
Any Known Problems? Yes No If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: (11 Number Of Bedrooms:
✓ 3 Number of People
Pool Size: �l (� Garage Size: Other: •--
Requested By: Date Requested:
(SignaMro 4 V
For Environmental Health Office Use Only
Approved Disapproved
Comments:
Environmental Health Specialist I 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 properly for any given period of time.
Payment: Cash Check Money Order #
Amount:$
Paid By: Y Received By:
Account #: p Invoice #:
v
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