566 Howardtown Circle • OPERATION PERMIT or ice se Only
Davie County Health Department *CDP File Number 187517-1
210 Hospital Street
F6-000-00-106-05
P.O.Box 848 County ID Number.
Mocksville NO 27028 Evaluated For. REPAIR
Phone:336-753-6780 Fax:336-753-1680 Township:
Applicant: Cynthia M. Carter Property Owner: Cynthia M. Carter
Address: 566 Howardtown Circle Address: 566 Howardtown Circle
City: Mocksville City: Mocksville
State0l): NC 27028 State/Zip: NC 27028
Phone#: (336)816-2641 Phone#: (336)816-2641
- Property Location & Site Information
Address/Road #: Subdivision: Phase: Lot:
566 Howardtown Circle
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 158 turn right on Howardtown Circle 1 mile On
right.
#of Bedrooms: 3
#of People:
*Water Supply: PUBLIC
*IP Issued by. *System Classification[Description:
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by: 2140-Nations,Robert Saprolite System? QYes QNo
Design Flow: 3 6 0 GRAVITY-SERIAL Pump Required?
Distribution Type: QYes QNo
Soil Application Rate: 0 a 7 5
*Pre Treatment:
Drain field
Nitrification Field 1 3 0 9 Sq. *System Type: INFILTRATOR QUICK4STANDARD
No. Drain Lines 5 Installer: Randy Muer
Total Trench Length: 3 2 7 ft. Certification#: 1128
Trench Spacing: _ 9 Inches O.C.
+ Feet O.C. *EH S: 2140-Nations,Robert
Trench Width: _ 3 Qlnches
Q* Feet Date: 0 7 / 0 1 / .1 0 1 5
Aggregate Depth: inches
Minimum Trench Depth: 3 6 Inches
Minimum Soil Cover. Inches 4 EiR.
ApprovaCStatusMaximum Trench Depth: 3 6 Inches proved "Disapproved
Maximum Soil Cover:
2 4 Inches
CDP File Number 187517 - 1 County ID Number: FB-000-oa106.Os
Septic Tank
Manufacturer. Lat.
Long:
STB:
Gallons: Installer
Date: Certification#f:
*EHS:
*Filter Brand:
ST Marker. ❑ Yes ❑ No Date:
Reinforced Tank: ❑ Yes ❑ N0 Approval Status
Piece Tank: ❑ Yes ❑ No 0. ';'A- proved❑ ;Disapproved
Pump Tank
Manufacturer. Installer.
PT: Certification#:
Gallons: THS:
Date: Date: j
RiserSealed ❑ Yes ❑ No
RiserHeight: ❑ Yes . ❑ No (Min.6 in.) AppiovalStatUS'
Reinforced Tank: ❑ Yes ❑ No ❑ Approved❑ Disapproved
1 Piece Tank: .❑. Yes . ❑ No
Supply Line
Pipe Size: inch diameter Installer.
Pipe Length: feet Certification#:
*Schedule:
THS:
Pressure Rated ❑ Yes ❑ NO Date.
Approved fittings ❑ Yes ❑ NO Approval Status
❑ Approved C1 Disapprove
Pump e
CDosing
p Type: Installer.
Volume: — Gal Certification#:
Draw Down: Inches *ENS:
*Chain:
Date:
Valves Accessible ❑ Yes ❑ NO
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve ❑ Yes ❑ No Approval Status
PVC unions El Yes ❑ No ❑ Appro'ved D Disapproved
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole ❑ Yes 0 NO
CDP File Number 187517 - 1 County ID Number: F6.000.00.106.05
Electric Equipment
NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer.
Box 12 inches Above Grade ❑ Yes ❑ No
Certification#:
Box Box
Pump Tank ❑ Yes ❑ No
Conduit Sealed ❑ Yes ❑ No 'EHS:
Pump Manually Operable ❑ Yes ❑ No
'Activation Method: Date: /
Approval Status
Alarm Audible ❑ Yes ❑ No
Approved❑ .Disapproved
Alarm Visible ❑ Yes ❑ No
2140-Nations,Robert
'Operation Permit completed by:
Authorized State Agent: Date of Issue: 3 / 0 1 / 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. Seq.,and all conditions of the Improvement Permit and
Construction Authorization.This property Is served by a TYPE If A. sewage septic system.
Rule.1961 requires that a Type. TYPE Il 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 home/business 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 entitywith 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 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. 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 187517 , 1
Davie County Health Department CDP File Number:
210 Hospital Street F6-000-00-106-05
P.O.Box 848 County File Number:
Mocksvilie NC 27028 Date:
Olnch
Drawing Drawing Type: Operation Permit Scale: O�o k ft.
0
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• CONSTRUCTION For Office Use Only
AUTHORIZATION *CDP File Number 187517- 1
•'"L"F' Davie County Health Department County ID Number: F6 00o-oo-yos-o5
210 Hospital Street Evaluated For: REPAIR
.� ,s. P.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone: 336-753-6780 Fax: 336-753-1680 0 3 / 1 3 / a 0 a 0
Applicant: Cynthia M. Carter Property Owner: Cynthia M. Carter
Address: 566 Howardtown Circle Address: 566 Howardtown Circle
City: Mocksville City: Mocksville
State/Zip: NC 27028 State/Zip: NC 27028
Phone#: (336)816-2641 Phone#: (336)816-2641
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
566 Howardtown Circle
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 158 turn right on Howardtown Circle 1 mile on right.
#of Bedrooms: 3
#of People:
*Water Supply: PUBLIC
System Specifications
Minimum Trench Depth: a 4
rDesign
cation: Provisionally suitable Inches
Minimum Soil Cover:
tem? OYes ®No 1 a Inches
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) $eptic Tank:
Gallons
*Proposed System: 25%REDUCTION 1-Piece: O Yes O No
Pump Required: OYes 0 N O May Be Required
Nitrification Field 1 3 0 9
Sq.ft. Pump Tank: Gallons
No. Drain Lines 5 1-Piece: OYes ONo
Total Trench Length: 3 a 7 ft GPM—vs— ft. TDH
Trench Spacing: Inches O.C.
g Feet O.C. Dosing Volume: Gallons
Trench Width: — 3 2Inches
®Feet Grease Trap: Gallons
Aggregate Depth:
inches Pre-Treatment: O NSF OTS-1 OTS-II
Septic Tank Installer Grade Level Required: 01011 O III ON
Page 1 of 3
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CDP File Number 187517 - 1 County ID Number: F6-000-00-106-05 .
❑ Open Pump System Sheet
Repair System Required:0 Yes O No O No, but has Available Space
CDesign
System
Trench Spacing: O Inches O. .
ification: — O Feet O.C.
Trench Width: O Inches
w: — O Feet
Soil Application Rate: Aggregate Depth: inches
.� Minimum Trench Depth:
*System Classification/Description: Inches
Minimum Soil Cover:
Inches
Maximum Trench Depth:
*Proposed System: Inches
Nitrification Field
Sq. ft. Maximum Soil Cover: Inches
No. Drain Lines *Distribution Type:
Total Trench Length: ft Pump Required: OYes O No O May Be Required
Pre-Treatment: ONSF OTS-I OTS-II
"l-)
*Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. Rema;gig
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;ng
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(8)).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 3 / 1 3 / a 0 1 5
Authorized State Agent: 0 - Malfunction Log OYes
®Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION 187517 - 1
Davie County Health Department CDP File Number:
210 Hospital Street F6-000-00-106-05
P.O.sox 848 County File Number:
Mocksville NC 27028 Date: 0 3 / 13 / .1015
O Inch
Drawing Drawing Type: Construction Authorization Scale: . 00 Block ft.
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CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street CDP File Number: 187517 - 1
P.O.Box 848 176-000-00-106-05
Mocksville NC 27028 County File Number:
Date: A3./ 13 / .1 0 15
Click below to import an image from an external location: Drawing Type. Construction Authoriz tion
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