258 Howardtown CircleOPERATION PERMIT
Davie County Health Department
r- 210 Hospital Street
P.O. Box 848
Mocksville NO 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Joseph Allen Brewer
Address: 258 Howardtown Circle
City Mocksville
State2ip: NC 27028
Phone #: (336) 998-7789
Address/Road M - Subdivision:
258 Howardtown Circle
Mocksville NC 27028
Structure: OTHER
# of Bedrooms:
# of People:
'Water Supply: PUBLIC
'IP Issued by. 2140 -Nations, Robert
*CA issued by: 2140 -Nations, Robert
Design Flow: 1 0 0
Soil Application Rate: 0 - a
P erty Owner. Joseph Allen Brewer
Address: 258 Howardtown Circle
City Mocksville
State2ip: NC 27028
Phone #: (336) 998-7789
Phase:
Directions
Hwy 158 right on Howardtown Circle
Lot:
*System ClassificationtDescription:
TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
SaproliteSystem? ( Yes @No
*Distribution Type: GRAVITY- PARALLEL (eq. d -box) Pump Required?
OYes ONo
'Pre Treatment:
rain field
Nitrification Field
5 0
0 Sq. ft.
'System Type: INFILTRATOR QUICK 4 STANDARD
No. Drain Lines
a _
Installer: Jamie Bames
Total Trench Length,
1 0 0 ft.u:
Certification TM 1018
Trench Spacing:
9
Inches O.C.
Feet O.C.
'EH S: 2140 - Nations, Robert
Trench Width:
— 3
inches
Feet
0 3/ 3 0/ 2 0 1 6
Date:
Aggregate Depth:
inches
CDP File Number 198629 - I
Manufacturer. Shoat
STB:
760
Gallons:
1000
Dosing Volume:
Date:
0 a/
0 3/
2 0 1 6
*Fitter Brand:
POLYLOKPL-122 With Pipe Adapter
ST Marker:
1:1 Yes
1B
No
nforced Tank:
EJ Yes
@1
No
1 Piece Tank:
C3 Yes
on
No
Ac Tank County ID Number:
Lat.
Long:
Installer: Jamie bOmOs
Certification #: 1018
*EHS: 2140 - Nations, Robert
Date: 0 3/ 3 0/ 2 0 1 6
Pump Tank
Manufacturer Installer
.PT:
Gallons:
Installer:
Dosing Volume:
Date.
Gap Certification
Riser sealed n
Yes
0
No
Riser Height: [1
Yes
0
No (Min. 6 in.)
einforced Tank-, 0
Yes
0
No
1 Piece Tank: 0
Yes
C1
No
Pipe Size: inch diameter
Pipe Length: feet
*Schedule:
Pressure Rated El Yes n No
,pprovedfdtings El Yes El No
Certification 9:
*EHS:
Date:
Apply Line
Installer:
Certification #:
'EHS:
Date:
Pump Type:
Installer:
Dosing Volume:
Gap Certification
Draw Down:
Inches
*EHS:
*Chain:
Date:
Valves Accessible
El
Yes
0
No
Flow Adjustment Valve
0
Yes
El
No
Check -valve
El
Yes
1:1
No
PVC Unions0
Yes
El
No
Vent Hole
[:]
Yes
El
No
Anti -siphon Hole
El
Yes
0
No
CDP File Number 198629 -1
NEMA 4X Box or Equivalent
Box 12 inches Above Grade
Box Adj. To Pump Tank
Conduit Sealed
Pump Manually Operable
*Activation Method:
County ID Number:
Approval Status
Alarm Audible ❑ Yes ❑ No
-73'
Approved Oj Disapproved
Alarm Visible ❑ Yes ❑ No
40 • Nations. Robert
*Operation Permit completed by: At
Authorized State
Owner/Applicant Signature:
0'
Date of Issue: 0 3/ 3 0/ 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 Ila sewage septic system.
Rule .1961 requires that a Type TYPE 11 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:
NA
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 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 avalid contract with a
public management entitywith 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 owner and certified operator are the same. The contract shall require specific requirements for maintenance 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.
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Electric Equipment
❑ Yes
❑
No
Installer:
❑
Yes
❑
No
Certification#:
❑
Yes
❑
No
❑
Yes
❑
N o
*EH S:
❑
Yes
❑
No
Date:
Approval Status
Alarm Audible ❑ Yes ❑ No
-73'
Approved Oj Disapproved
Alarm Visible ❑ Yes ❑ No
40 • Nations. Robert
*Operation Permit completed by: At
Authorized State
Owner/Applicant Signature:
0'
Date of Issue: 0 3/ 3 0/ 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 Ila sewage septic system.
Rule .1961 requires that a Type TYPE 11 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:
NA
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 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 avalid contract with a
public management entitywith 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 owner and certified operator are the same. The contract shall require specific requirements for maintenance 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.
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT 198629-1
Da)Ae County Health Department CDP File Number:
210 Hospital Street
P.O. Box M County File Number:
Mocksville NC 27028 Date: /
.. A ---A �•
Q inch
Drawing Drawing Type: Operation Permit Scale:. QBtck = ft.
QN/A
b
It
I i
E
i I l
Y 7
�.r
JT-T-��v
§ ; a
3 8
( e i
i _ m
7 E
�4
Date
Topic e W ev
Meeting Objectives
Notes
Attendees
Action Items
CONSTRUCTION For Office Use Only
AUTHORIZATION *CDP File Number 198629-1
-.1.4zw. D' Davie County Health Department
County ID Number:
210 Hospital Street Evaluated For: NEW
P.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone: 336-753-6780 Fax: 336-753-1680 1 a/ 1 6/ a 0 a 0
Applicant: Joseph Allen Brewer Property Owner: Joseph Allen Brewer
Address: 258 Howardtown Circle Address: 258 Howardtown Circle
City: Mocksville City: Mocksville
State/Zip: NC 27028 State/Zip: NC 27028
Phone #: (336) 998-7789 Phone #: (336) 998-7789
.I-
Address/Road
Address/Road #: Subdivision:
258 Howardtown Circle
Mocksville NC 27028
Structure: OTHER
# of Bedrooms:
# of People:
*Water Supply: PUBLIC
Phase: Lot:
Directions
Hwy 158 right on Howardtown Circle
SDecifi
Site Classification: Provisionally suitable
Minimum Trench Depth:
a
Inches
4\
Saprolite System? OYes ® No
Minimum Soil Cover:
1
a Inches
Design Flow: 1 0 0
Maximum Trench Depth:
3
6 Inches
Soil Application Rate: 0 a
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)
S t; T k'
*Proposed System: 25016 REDUCTION
Nitrification Field
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Aggregate Depth:
5 0 0 Sq. ft.
up Ic an . 1 0 0 Gallons
1 -Piece: OYes ® No
Pump Required: OYes ®No O May Be Required
Pump Tank: Gallons
a 1-Piece:OYes ONo
1 a 5 ft. GPM --vs-- ft. TDH
Inches O.C.
g Feet O.C. Dosing Volume: Gallons
3 Olnches
® Feet Grease Trap: Gallons
inches Pre -Treatment: O NSF OTS -1 O TS -II /
Septic Tank Installer Grade Level Required: 01011 OIII 01V
Page 1 of 3
CDP"File Number 198629 -1
*Site Modifications
County ID Number
M Open Fill Sheet
No grading or constructionactivityis. allowed in areas designated for system and repair _without , approval of Health Department.
*Permit Conditions
The -issuance of this permit by the Health Department in no guarantees the issuance of other permits. The perm ft. holder
is responsible for checking with 6ppro , pri . ate governing bodies I in meeting their I req . u " irern I ents.
Theimprovernent Permit shall be valid for 5years frorn date of Issue with a site plan (meansa drawing not necessarily drawn to
SH6 Plan scale that shows the existing aril proposed property lines with dimensions, the location of the facility and appurtenances, the
site forthe proposed Wastewater system, and the location of water supplies and surft"Watqrs),
Plat The Im provement Permit shall be valid without expiration with plat (means a prop" survWed prepared by a registered land
surveyor, drawn to a scale of one Inch equals no more than 60 feet that includes: the specific location of the proposed facility
and appurtenances, the sitefor the proposed Wastewater system, and the location of water supplies and surface waters. Plat
also
I so means, . #or subdivision iots approved by the local . planning authority . and . recorded
ed with the'co unty 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 Issuanceand 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 (HOGS 1, 3'DA435M). The person owning or controlling the iystemshall be responsible f0tassuring compliance
With the laws, rules, and permit condition9 system location, Installatls regardin on, operation:operation:malntenance4 monimonitoring,n
reporting, and repair , (A ga(b)
ftplicaqfteg-al Reps -Signature Required? 0 -Yes QNo
I!
ApplitantlLegal Reps. Signature;
*Issued By: 2140 - Nations, Robert Date of Issue: 1 -2 / 1 6 / c? 0 1 5
ut Expiration?
OValid without Authorized State Age` -
.0 C reate CA. 7
01 -land Drawing 01rnport 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:
Date: 1,2/ 16 /,2015
0 Inch
Scale: 0 Block
0 N/A
Page 3 of 3
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Page 3 of 3
Pi P2
5
a.
U
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
CDP File Number:
County File Number:
Date:.l.•./ 16 /.2 0 15
Click below to import an image from an external location: Drawing Type: Construction Authorization
Page 3 of 3
P1
P2
IMPROVEMENT PERMIT
r� Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville. NC 27028
r For Office Use Onlv
"CDP File Number 198629.1
County ID Number:
Evaluated For. NEW
Township:
Phone. 336-753-6780 Fax. 336-753-1680 PERMIT VALID UNTIL: 12/16/2020
"NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit.
Applicant: Joseph Allen Brewer
Address: 258 Howardtown Circle
CRY Mocksville
Statefzip: NC 27028
Phone # (336) 998-7789,
Address/Road #: Subdivision:
258 Howardtown Circle
Mocksville NC 27028
Structure: OTHER
# of Bedrooms:
# of People:
*Water Supply: PUBLIC
: Provisionally Suitable
Saprolite System? OYes @No
Design Flow: 1 0 0
Soil Application Rate: 0 2
u
"System Classification/Description:
TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR
LESS)
"Proposed System: 25% REDUCTION
Property owner. Joseph Allen Brewer
Address: 258 Howardtown Circle
City: Mocksville
StatefZip: NC 27028
Phone # (336) 998-7789
Phase: Lot:
Directions
Hwy 158 right on Howardtown Circle
Minimum Trench Depth: a 4 Inches
Maximum Trench Depth: 3 6 Inches
Septic Tank:
1 0 0 0 Gallons
1 -Piece: OYes QNo
Pump Required: OYes (ENo.Omay Be Required
Pump Tank: Gallons
1 -Piece: OYes ONo
Repair System Required:QYeS ONo ONo, but has Available Space
/rRepair System
( *Site Classification: Provisionally Suitable
Soil Application Rate: 0 a
*System Classification/Description
TYPE 11 A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR
LESS)
"Proposed System: 25% REDUCTION
Minimum Trench Depth 2 4 inches
Maximum Trench Depth: 3 6 Inches
Pump Required: Oyes @ No O Maybe Required
Pagel of 3
CDP File Number 198629 - 1
County ID Number:
❑ Open Pump System Sheet
uirea:%4Y rIrs LJ IVU k-JIVU, WUL IIdb FiVdIIdUIU OpdGC
*Site Classification: Provisionally Suitable
Design Flow: 1 0 0
Soil. Application Rate: 0 a
*System Classification/Description:
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR
LESS)
*Proposed System: 25% REDUCTION
Nitrification Field 5 0 0
Sq. ft.
No. Drain Lines a
Total Trench Length: 1 a 5
ft.
Trench Spacing: 9 O Inches O.
Weet O.C.
Trench Width:3 O 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 (& 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. CRemaining
haracters
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 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:. 1 a / 1 6 / a 0 1 5
Authorized State Agent- Malfunction Log O Yes ..t
(9 Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT &ATC
EJ) Davie County Environmental Health P
P.O' Box 848/210 Hospital Street Dace: AID
Mocksville, NC 27028
(336)753-6780/ Fax (336)753-1680
Application For: Site Evaluation/Improvement Permit ❑ Authorization To Construct (ATC) 0 Both
Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modifwation 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.
APPLICANT INFORMATION
Name 0.50f\ 4!MeAi /e -w t„
Address 9,5V a4iARi7r)e,�U 0-,l-
City/State/ZIP Ine,-k�'rr. %/r N. C.
Email i0% 4hcAdl,4A2'r.JPrl�i 4rl"4,7a eniv1.
Name on
Address
ATC if Different than Above
FKUFhKl Y 1NPUEMA11UN
Contact Person 1Q11,t/ di-cVc 61—
Home Phone 37a -99g 7?g19
Business Phone
Email: 54
"Date House/Yacility Corners
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 : Am Phone Number 1MI'K-t,
Owner's Address QA nr-- & City/State/Zip___ SA/h
Property Address AtA e- City A /►1�
Lot Size Tax PIN#
Subdivision Name(if applicable) Section/Lot#
Directions To Site:
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?
Yes
_No
Does the site contain jurisdictional wetlands?
_Yes
_No
Are there any easements or right-of-ways on the site?
_Yes
No
Is the site subject to approval by another public agency?
_Yes
_No
Will wastewater other than domestic sewage be generated?
Yes
No
IF RESIDENCE FILL OUT THE BOX BELOW
# People # Bedrooms # Bathrooms Garden Tub/Whirlpool ❑Yes ❑No
Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No
IF NON -RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business 4gaa 54o p Total Square Footage of Building People 12
# Sinks _�^ # Commodes �_ # Showers n # Urinals 0
Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: # Seats
Type system requested: Pdo'nventional ❑Accepted ❑Innovative ❑Altemative ❑Other
Water Supply Type: OfCounty/City Water ❑ New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes R<O
If yes, what type?
This is to certify that the information provided on the 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 charges, 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 locating and flagging
or aking the house/facili location, proposed well location and the location of any other amenities.
Site Revisit Charge
P e owner's or owner's legal representative signature
Date(s):
/(- 3c? -a6 Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account #
I o 1p
Revised 11/06 Invoice 0
All data is provided as Is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the Implied
warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of
Davie, North Carolina, Its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out
S of the use or Inability to use the GIS data provided by this website.
OD
Printed:Nov 30, 2015
APPLICANT INFORMATION
Jv h (�rv�er
33� 4094h&
Water Supply: On -Site Well
-f
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
Community
PROPERTY INFORMATION
A WUA wle;rcl&
�aP
Public ~
Evaluation By: Auger Boring Pit Cut
FACTORS
1 2 3 4 5 6 .7
Landscape position
Slope %
HORIZON I DEPTH
G —
Texture groupL
Consistence
t
Structure
Mineralogy
HORIZON II DEPTH
Texture group
<--
Consistence
-j
Structure
Mineralogy
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
a—
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: 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
05 M,
VFR - Very friable FR - Friable FI - Firm VFI - Very firm FYI - 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
Nato
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 - Lone -term acceptance rate - eal/davM2 TIMM ncinc M-4—AN