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125 Hunters Trails a . OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O Box 848 Mocksville; NC 2702& Phone: 336-753-6780 Fax: 336.753-1680 Applicant; JoyceBarnes Bullard Address: 294 Splitcreek Lane City: Mocksville State/Zip: NC 27028 Phone #: Property owner. Joyee Bames Bullard Address: 294 Splitcreek Lane City: Mocksville State/Zip: NC 27028 Phone #: Pro a Location & Site Information #: Subdivision: Phase: Lot: rAddress/Road '125 Hunters Trail Advance NC 27006 Directions Hwy 64 E, left on Hwy 801, left on Bailey's Chapel Structure: SINGLE FAMILY Rd. Hunters Trail on left past Church # of Bedrooms: # of People: *Water Supply: NIA "IP Issued by. 214o-Nations,Ftobert 'System Classification/Description: TYPE It A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) ICA issued by: 2140. Nations, Robert SaproliteSystem? OYes @No Design Flow: 3 6 0 *Distribution T GRAVITY- PARALLEL (eq. d -box) Pump Required? Type: (Yes QNo Soil Application Rate: 0 - a 7 5 *Pre -Treatment: Drain field Ntriflcation Field Sq. ft. *System Type: INFILTRATOR OUICK4STANDARD No. Drain Lines Installer. Jamie Samos Total Trench Length: 1 0 0 ft. Certification #: Trench Spacing: _ 9 Inches O.C. §r Feet O.C. *EH S: 2140 - Nations. Robert Trench Width: _ 3 Inches %Feet 0 2/ 0 1/ 2 0 1 6 Date: W Aggregate Depth: inches Minimum Trench Depth: 4 0 Inches Minimum Soil Cover. a $ Inches Approval Status` fir Maximum Trench Depth: 4 0 �raM . ij Approvetl Cl Disapproved Inches Maximum Soil Cover: 2 8 Inches CDP Fite Number 198338 - 1 County ID Number: c Manufacturer. STB: ❑ No Flow Adjustment Valve ❑ Yes Gallons: NO Check -valve ❑ Yes ❑ Date: Cyt; PVC Unions ❑ Yes ❑ 'Filter Brand: Vent Hole ❑ Yes ❑ ST Marker ❑ Yes ❑ No nforced Tank: ❑ Yes ❑ No 1 Piece Tank: t ❑ Yes ❑ No P ' Manufacturer. PT: Gallons: Date: RiserSealed E3Yes ElNo RiserHeight: E3Yes ❑ No (Min.6 in.) einforced Tank: ❑ Yes ❑ No `1 Piece Tank: ❑ Yes 13No Pipe Size: inch diameter Pipe Length: feet "Schedule: Pressure Rated [:1Yes ElNo ipproved fittings ❑ Yes ❑ No mic TanK Let. Long: Installer. Certification #: THS: Date: u mp Tank Installer Certification #: TH S: Date: upply Line Installer Certification #: THS: Date: / Pump Type: Installer. Dosing Volume: - Gal Certification #: Draw Down: Inches THS: *Chain: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ NO Check -valve ❑ Yes ❑ No Cyt; PVC Unions ❑ Yes ❑ No Vent Hole ❑ Yes ❑ No Anti -siphon Hole ❑ Yes 0 No Pipe Size: inch diameter Pipe Length: feet "Schedule: Pressure Rated [:1Yes ElNo ipproved fittings ❑ Yes ❑ No mic TanK Let. Long: Installer. Certification #: THS: Date: u mp Tank Installer Certification #: TH S: Date: upply Line Installer Certification #: THS: Date: / Pump Type: Installer. Dosing Volume: - Gal Certification #: Draw Down: Inches THS: *Chain: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ NO Check -valve ❑ Yes ❑ No Cyt; PVC Unions ❑ Yes ❑ No Vent Hole ❑ Yes ❑ No Anti -siphon Hole ❑ Yes 0 No y„ CDP File Number 19$33$ - 1 NEMA4X Box or Equivalent ❑ Yes ❑ No Box 12 inches Above Grade ❑ Yes ❑ No Box Adj. To Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No Pump Manually Operable ❑ Yes ❑ No 'Activation Method: AlarrnAudible ❑ .Yes ❑ No Alarm Visible E3 Yes [:3No 2140 - Nations. Robert *Operation Permit completed by' Authorized State County ID Number: Installer Certification #: *EH S: Date: / I Approval Status: ,.❑Approved ❑ I7isappro`ted` Date of issue: 0 a/ 0 1/ a 0 1 6 Owner/Applicant Signature: This system has been installed in compliance with applicable NC General Statutes: Article 11, Chapter 130A, Rules for Sewage Treatment and, Disposa1,15A'NCAC 1$A .1900 et. Seq.,and all conditions of the improvement Pennnit and Construction Authorization. This property is seared by a TYPE It A sewage septic system. Rule .1961 requires that a Type TYPE IIi A septic system meet the following criteria: Maximum System Review ByThe Local Health Department: NIA Management Entity: OWNER Minimum System InspectionlMaintenance Frequency By Certified Operator: NIA Reporting Frequency By Certified Operator. NIA Rule .1.961. 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 operator ore private certified operatorfor the life ofthe septic system: Rule .1961 requires thatType VI septic systems designed for a 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 alt (iperation Permit for asystem, required to be maintained b public or private rnanagement;entty, unless the system owner and certified operatorare the same. The contract shall require specific requirements formaintenance and operation, responsibilities of the ownerand systems operator, provisions thatthecontractshall be in effect .for aslong as the system is in use, and otherrequirements forthe.continued proper performance of the systema ft shall also be acondition of the Operation Permit that'' subsequent owners hof the systems execute such a contract. *Hand Drawing Qlmpod Drawing **Site Plan/Drawing attached.** fx. OPERATION PERMIT Davie County Health department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawin Drawing Type: Operation Permit 44 CDP File Number: 198338-1 County File Number: Date: I 1 OInch Scale: OBlock ON/A Phone: (336) - 753-6780 Davie County Health Department Environmental Health Section P.O. Box 848 210 Hospital Street. Courier # : 09-40-06 Mocksville, NC 27028 Fax: (336) - 753-1680 NOTICE OF VIOLATION ON-SITE WASTEWATER SYSTEM Owner Joyce Barnes Bullard Mailing Address 294 Splitcreek Lane; Mocksville, NC 27028 Occupant Joyce Barnes Bullard Location 125 Hunters Trail; Advance, NC 27006 (X) Residence O Business O Other Dear Mrs. Bullard, You are hereby notified that you are violating the Rules adopted by the North Carolina commission for Health Services or Article 11 of Chapter 130A of North Carolina by owning or controlling a residence, place of business, or place of public assembly which is not provided with an approved wastewater system. Your wastewater system is not in compliance. A portion of your septic system is located on an adjacent property and must be moved to meet setbacks. On _December 14, 2015_, an inspection of the wastewater system by the Davie Environmental Health Department indicated the following violations: VIOLATION/S LAW OR RULE CITE Responsibilities 15A NCAC 18A.1938 Location of Sanitary Sewage System 15A NCAC 18A.1950 Your are here by ordered to bring you wastewater system into compliance by completing one of the following. (X ) Install/Repair wastewater system. () Other Repairs (Specify) () Eliminate wastewater discharge and () Perform Maintenance (Specify) Connect to an approved wastewater System. If the wastewater violation is not brought into compliance by January 30, 2016_, Appropriate legal action will be taken. Failure to comply with the laws, rules and this notice will subject you to the following legal remedies; Injunction Relief (G.S.130A-18), Administrative Penalties (G.S.130- 22(c) ), Suspension or Revocation of Permits (G.S.130-32), and Criminal Penalties (G.S. 130-25). You may contact our office at (336) 753-6780 or fax; (336) 753-1680 Davie COUNTY 210 Hospital Street P.O. Box 848 Mocksville NC 27028 TEL: 336-753-6780 FAX:336-753-1680 Request ID: 61322 REQUEST FOR SERVICE/COMPLAINT INVESTIGATION REPORT REQUEST DATE: 11/03/2015 TAKEN BY: SECTION: N/A TYPE: PROPERTY NUMBER: 198338 ASSIGNED TO: Nations, Robert ESTABLISHMENT NUMBER: PERSON OR PREMISES TO SEE: Joyce Barnes Bullard 125 Hunters Trail Advance NC, 27006 OWNER: Joyce Barnes Bullard 294 Splitcreek Lane Mocksville , 27028 REQUESTED BY: HOME:li//� n q ��C"/•�����/���%(� WORK: Cell: CONDITION REPORTED:Septic over flowing 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 £ro 1233 � 1 07 %5 _ - `--1 mx 107 E z 106 X11 is ",_1 46 109 11 1 05 " 3 ` , 1 I `1 vr _ 70 .... , ILI 1 ' � 1r76s A , i X1 , 3 DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST APPLICATION IP/ATC OSWW REPAIR Name �te r Telephone Number Address Mailing Address (if different from above) Email Address: Subdivision Name Directions K99n Date System Installed Type Facility Type Water Supply _ Lot # 0 / Name System Installed Under Number Bedrooms Number People Served pecific Problem Occurring Date Requested f 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 DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST / ' APPLICATION IP/ATC OS. REPAIR'i.. C t Name 4✓ r„ Telephone Ntmber 4 Address,, rd Mailing Address (if different from above); Email Address: JCC l 1, :? Subdivisidn Name Lot #` Directions 119 r e -J_ a �(U� % Date SystT�Installed J 'moi ,. Name System Installed Under f Type Facility!I4umberb ooms Number People Served Type W , ..: ater Supply ! ^�, ,pecific Problem Occurrin g Date Requested /`Info Taken By S/,�/c THIS -IS TO CE TIq ThAT THE INFORMATIOWP&VIDED IS CORRECT TO THE BEST OF MY KNOWLEDGE,W iND THAT I DERS TI=Pk I1AM RESPONSIBLE FOR ALL CHARGES INCURRED FROM THIS APPLICATION. ,- Signature of owner or Autho�e gnt f Initial Fee DIte-"r HS tit > "r Resit"Charge . Date. Reason vir Revised 2-2011 7� �^*"-�^ ~1~~^~^~~~'----~''-~--- --` DAVIE COUNTY HEALTH DEPARTMENT ' _-___''_--_-'_- ___'__ -''_____'_'-'__ -_ ----_ __- U����������� PERMIT AND ���������� �� ��������N *NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 18o ° Se age Trea ent and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Namo___--D��* ��� ��u�� .^.. _ . ... Location Subdivision'Name Lot No. Sec. or Block No. Lot Size House Mobile K4nbi|e Homo |// � Business __-_--__ Speculation -_-_----_ � -� No. Bedrooms __-_-_---No. Baths __---_-_No. inFamik/--��-_--- Garbage Disposal YES :[-] NO E] Specifications for System: Auto Dish Washer YES F-1 NC) -,E) ` Auto Wash Machine YES E]' NO -E] Type VVab»r Supply ` *This permit Void if sewage system described below is not installed within 36 months from date of issue. Improvements permit by ^Contaucta representative of the Davie County Health Department for final inspection of this aynh*m between 8:30- 9:30 A.M. :30'S:3OA.K4. or 1:00'1:30 P.M. on day of completion. Telephone Number: 7U4 -O34-5885. Final Installation Diagram: System Installed by 100 ~ ��icate of Completion Date 'The signing of this certificate ahoU indicat` that the system described'above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. ' r APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT Davie County Health Department * 1 # d o .,, •, • Environmental Health Section � d�1 FJ01 P. O. Box 665 R R� Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN (ISSUED. p Home Phone "/ jfo - 7 3 1. Permit Requested By /� JjN �e r� Crz S 0� ��b�c`e Business Phone (035L Sof O f 2. Address r? 3 s G3 AR�� ,! C L (� �/�' y0Y ti ✓� l' �� M +.z o N S. X, r x d/2- 3. 23. Property Owner if Different t an Above L ©! 13,4 Z, Address C C, .20606 4. Permit To: a) Install Alter Repair b) Privy Conventional Other Type Ground Absorption c) Sub -Division Sec. Lot No. 5. System used to serve what type facility: House Mobile Home l Business Industry Other b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions $ / Bed Rooms _ Bath Rooms— Den w/Closet b) If Business, Industry or Other, State: Number of persons served What type business, etc. Estimate amount of waste daily (24 hours) 7. Number and type of water -using fixtures: commodes urinals garbage disposal lavatory 2 showers 2 washing machine_-� dishwasher 1 sinks / 8. a) Type water supply: Public Privatej/Community b) Has the water supply system been approved? Yes No -1-10"r 9. a) Property Dimensions :± de-ocz6o % b) Land area designated to building site c) Sewage Disposal Contractor UPJkN a Lyto 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?� What type? This is to certify that the information is correct to the best of my knowledge. M Date Owner Signature. OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: c WA,,� a;,-� �7 DCHD (6-82) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION /�, Date " I �� Lot Size Name "4. �\� 5 e a Address tk. c' -Q c FA rTr) RC Ai -Wil 1 \ ARFA 7 ARFA :3 ARFA A 1) Topography/ Landscape Position S PS S PS U U ?) Soil Texture (12-36 in.) Sandy, S S PS Loamy, Clayey, (note 2:1 Clay)PS U U U 3) Soil Structure (12-36 in.) Clayey SoilsPS Ei S PS S PS U U I) Soil Depth (inches) S S PS PS U U U i) Soil Drainage: Internal S S S - S PS PS U U U U External S S pS PS PS U U U i) Restrictive Horizons Available Space SS S ©(Z PS PS U U U U 1) Other (Specify) S PS S PS S PS S PS U U U i) Site Classification U—UNSUITABLE S SVnAl5LE PS—Provisionally Suitable Recommendations/Comments: Described by Q-1- T' e SITE DIAGRAM DCHD (6.82) Date