941 Howardtown Circle OPERATION PERMIT or fice use Unly
Davie County Health Department *COP File Number 192900-1
210 Hospital Street
P.O. Box 848 County ID Number.
Mocksville NC 27028 Evaluated For'REPAIR
Phone:336-753-6780 Fax:336-753-1680 Township
Applicant: JoAnn Blakeley, Property owner JoAnn Blakeley
Address: 1200 Howardtown Circle Address: 1200 Howardtown Circle
City Mocksville City: Mocksville
State2ip: NC 27028 :State/Zip: NC 27028
Phone#: 1,Phone#:
Property Location & Site Information
Address/Road #: Subdivision: Phase: Lot:
941 Howardtown Circle
Mocksville NC 27028 Directions
structure: OTHER Hwy 158, right on Howardtown Circle, on left just
past#899
#of Bedrooms:
#of People:
,water Supply: NIA
*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? OYes ONo
Design Flow: 4 8 0 'Dist ribution Type: GRAVITY-SERIAL Pump Required?
OYes ONo
Soil Application Rate: 0 - a 7 5 *Pre Treatment:
Drain field
rNorirDratiin
con Field 1 7 4 5 S4 ft. *System Type: INFILTRATOR QUICK 4 STANDARD
Lines Installer: Brian McDaniel
Total Trench Length: a a 8 It. Certification#: 1118
Trench Spacing: _ 9 Inches O.C.
+ Feet O.C. *EH S: 2140-Nations.Robert
Trench Width: 3 Inches
Feet Date: 0 3 / 0 6 / .1 0 1 5
Aggregate Depth: inches
Minimum Trench Depth: 3 6
Inches
Minimum Soil Cover. a 4 Inches Approval Status
Maximum Trench Depth: 3 6 Inches NI AO prove D'Isapprovetl
Maximum Soil Cover: a 4
Inches
CDP File Number 192900- 1 Septic Tank County ID Number:
Manufacturer. Lat.
Long:
STB: .
Gallons: Installer.
Date: Certification#:
"EHS:
"Filter Brand:
ST Marker. ❑ Yes ❑ No
Date:
Reinforced Tank: E] Yes El No ApjyrovatStatus
Piece Tank: ❑ Yes ❑ No ❑ Approved 0",
:Dasappraved ,
Pump Tank
Manufacturer Installer
PT: Certification#:
Gallons: THS:
Date: Date:
RiserSealed ❑ Yes ❑ No
RiserHeight:-❑ Yes ❑ No (Min.6 in.) Approval Status
Reinforced Tank: ❑ Yes ❑ No :O ;Approved❑-Disapproved
1 Piece Tank: ❑ Yes ❑ No
Supply Line
Pipe Size: inch diameter Installer.
Pipe Length: feet Certification#:
'Schedule: "EHS:
Pressure Rated ❑ Yes ❑ No Date:
Approved fittings ❑ Yes ❑ NO Approval Status
❑ Approved❑ Dlsappraved
Pump Requirement
Pump Type: Installer.
Dosing Volume: — Gal Certification#:
Draw Down: Inches 'EHS:
"Chain:
Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve ElYes ❑ Na APPIStatus
PVC unions ❑ Yes ❑ No ❑ Approved❑ Disapproved
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole ❑ Yes ❑ No
CDP File Number 192900 - 'I County ID Number:
Electric Equipment
N�4X or Equivalent ❑ Yes ❑ NO Installer
Box 12 inches Above Grade El 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 El Yes ❑ No ❑ -Approved❑ Disapproved
Alarm Visible ❑ Yes ❑ No
2140•Nations.Robert
*Operation Permit completed by:
Authorized State Ag Date of Issue: 0 7 / 0 6 / 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. Seq..and all conditions of the Improvement Permit and
Construction Authorization.This property is served by a TYPE n A sewage septic system.
Rule.1961 requires that a Type TYPE 11 A. septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: NIA
Management Entity: OWNER
Minimum System InspectionlMaintenanceFrequency ByCertified Operator.
WA
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 forthe life of the septic system.
Rule.1961 requires that Type VI septic systems designed fora hometbusiness owner must maintain a valid 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 ownerand 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. It shall also be a condition of
the Operation Permit that subsequent owners of the systems execute such a contract.
OHand Drawing Olmport Drawing
**Site Plan/Drawing attached.** r
OPERATION PERMIT 192900 -1
Davie County Heath Department CDP File Number:
210 Hospital Street
P.O.Box W County File Number:
Mocksvil►e NC 27028 Date:
Olnch
Drawing Drawing Type: Operation Permit Scale: , OON A k ft
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CONSTRUCTION
For Office Use Only
AUTHORIZATION A *CDP File Number 192900-1
• Davie County Health Department _! ��. County ID Number.
210 Hospital Street Evaluated For REPAIR.
' P.O. Box 848 Reaelved bvs
••.....• Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 0 4 / a 1 / a 0 a 0
Applicant: JoAnn Blakeley Property Owner: JoAnn Blakeley
Address: 1200 Howardtown Circle Address: 1200 Howardtown Circle
City: Mocksville City: Mocksville
State2ip: NC 27028 State0p: NC 27028
Phone#: Phone#:
Property Location & Site Information
FAddress/Road#: Subdivision: Phase: Lot:
ardtown Circle
e NC 27028 Directions
Structure: OTHER Hwy 158, right on Howardtown Circle, on left just past
#899
#of Bedrooms:
#of People:
'Water Supply: NIA
System Specifications
Minimum Trench Depth:
Site Classification: Provisionally Suitable Inches
Minimum Soil Cover.
Saprolite System? Oyes QNo Inches
Design Flow: 4 8 0 Maximum Trench Depth: Inches
Soil Application Rate: 0 - 1 7 5 Maximum Soil Cover. Inches
'System Classification/Description: 'Distribution Type:
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
Gallons
'Proposed System: 1-Piece: OYes ONo
Pump Required: OYes ONo OMay Be Required
Nitrification Field 1 3 0 9 Sq ft Pump Tank: Gallons
No. Drain Lines 1-Piece:OYes ONo
Total Trench Length: ft GPM vs— ft. TDH
Trench Spacing: _ 8Inch
tes O.C.
Dosing Volume: _ Gallons
Trench Width: Inches
8Feet Grease Trap: Gallons
Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-11
Septic Tank lnstallerGrade,Leve1 Required: OI OII 0111 OIV
Dflnn i of i
CDP File Number 192900- 1 County ID Number.
❑ Open Pump System Sheet
Repair System Required:OYes ONo ONo, but has Available Space
epair System
Trench Spacing: Q Inches 0. .
"Site Classification: — Q Feet O.C.
Trench Width: Q Inches
Design Flow: 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
Maximum Soil Cover:
Nitrification Field Sq.ft. Inches
No. Drain Lines "Distribution Type:
Total Trench Length: ft. Pump Required: Oyes ONo OMay Be Required
PreTreatment: ONSF OTS-1 OTS-II
'Site Modifications
No grading or construction activity is allowed in,areas designated for system and repair without approval of Health Department.
"Permit Conditions
The issuance of this permit bythe Health Department in no wayguarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements. ;
This Authorization for Wastewater system Construction shall bevalld fora person equal to the period of valldity of the improvement Permit,not
to exceed five years,and may be Issued atthe same time the Improvement Permit Issued(NCGS 130A-336(11)�If the installation has not been
completed during the period of validity of the Construction Permit,the information submitted in theapplication fora per mit 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 besuspended or revoked(.1937(g)).The person owning or controlling the system shall be msponsibleforassuring compliance
with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance,monitoring,reporting and repair
Applicant/Legal Reps.Signature Required? OYes ONO
Applicant/Legal Reps.Signature Date:,
"Issued By: 2140-Nations,Robert Date of Issue: - 0 . 4 / a 1 / a 0 1 5
Authorized State Age ctan Log OYesy
OHand Drawing Oimport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION
• Davie County Health Department CDP File Number: 192900- 1
210 Hospital Street
P.O. Box 848 County File Number:
Mocksville NC 27028 Date: 0 4 / 2 1 / 2 0 1 5
Otnch
Drawing Drawing Type: Construction Authorization Scale: . OBiock
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DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST
eevo)W"5-
APPLICATION IP/ATC OSWW REPAIR
Nal�' Telephone Number
Address A/g- 01
Mailing Address (if different from above) .
Email Address:
Subdivision Name Lot#
Directions lv UM101 r1e.,
Date System Installed 7i Name System Installed nder
Type Facility Number Bedrooms Number People Served
Type Wat r Supply Specific Problem Occurring 4 ��
CFr ifLAI
Date Requested Info Taken By
THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY
KNOWLEDGE,AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED
FROM THIS APPLICATION.
Signatµre of owner or Authorized Agent
Initial Fee Date REHS
Revisit Charge Date Reason
Revised 2-2011
ITAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST
APPLICATION IP/ATC OSWW�REPAIR
Name �CAVIi� Telephone Number •
Address
Mailing Address (if different from above) ,
Email Address ..
Subdivision Name Lot# "
Directions x/tl //(j r.L i 1 Y J/_/i/
Date System Installed r'f J ti Name System Installed Under
Type Facility - Number Bedrooms Number People Served
Type Water Supply JAf(� I( Specific Problem Occurring i iLi�
� �{.lf �•�.��, 1,r��,,�
Date Requested Info Taken By
THIS.IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY
KNOWLEDGE,AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED
FROM THIS APPLICATION.
Signature of owner or Authorized Agent
Initial Fee Date REHS
Revisit Charge Date Reason
Revised 2-2011 .
Davie COUNTY
210 Hospital Street
P.O. Box 848
Mocksville NC 27028 TEL: 336-753-6780 FAg: 336-753-1680 Request ID: 55720
REQUEST FOR SERVICE/COMPLAINT INVESTIGATION REPORT
REQUEST DATE: 04/09/2015 TAKEN BY:
SECTION: N/A TYPE:
PROPERTY NUMBER: 192900 ASSIGNED TO: Nations, Robert
ESTABLISHMENT NUMBER:
PERSON OR PREMISES TO SEE: OWNER: JoAnn Blakeley
JoAnn Blakeley 1200 Howardtown Circle
941 Howardtown Circle Mocksville , 27028
Mocksville NC, 27028
REQUESTED BY: HOME:
WORK:
Cell:
CONDITION REPORTED:Septic or other water running out
COMMENTS:
RECORD OF INVESTIGATION
DATE: HR/MT: COMMENTS
EHS:
EHS #:
ACT CODE:
DATE: HR/MT: COMMENTS
EHS:
EHS #:
ACT CODE:
DATE: HR/MT: COMMENTS
EHS:
EHS #:
ACT CODE:
DATE: HR/MT: COMMENTS
EHS:
EHS #:
ACT CODE:
DATE: HR/MT: COMMENTS
EHS:
EHS #:
ACT CODE:
Next Inspection Date: Status of Complaint: OPEN Resolved Date:
Complaintant Contacted: NO
DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST
APPLICATION IP/ATC OSWW REPAIR
•' C
Name jj d SW54& �/�SOX) Telephone Number
Address emda, 04,ev;116,
Mailing Address (if different from above)
Email Address:
Subdivision Name Lot
Directions i Jl �' C
AJ e 6AI9
Date System Installed Name System Installed Under
Type Facility Number Bedrooms Number People Served
Type Water Supply Specific Problem Occurring
Date Requested Info Taken By
THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY
KNOWLEDGE,AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED
FROM THIS APPLICATION.
Signature of owner or Authorized Agent
Initial Fee Date REHS
Revisit Charge Date Reason
Revised 2-2011
4,, • 4 ." �r .; i/t t : " , e:
"DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST
APPLICATION`IP/ATC,OSWW REPAIR
e
Name Telephone Number
Address 'V
Mailing Address (if different from above)
Email Address
Subdivision Name Lot
Directions v 1 ( 15-9'6F-
6 A
P� 59
Date System Installed Name System Installed Under
Type Facility Number Bedrooms Number People Served
Type Water Supply Specific Problem Occurring
t ,
Date Requested Info Taken By
THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY
KNOWLEDGE,AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED
FROM THIS APPLICATION. . ,.
Signature of owner or-Authorized Agent
Initial Fee Date) REHS
Revisit Charge Date R. > .-. Reason
Revised 2-2011
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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 Pri nted:Ma r 23 2015
CL1 of the use or Inability to use the GIS data provided by this website.
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