1999 Hwy 158OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Ann Morgan/ CTK Group LLC
Address: 4640 Cherry Hill Lane
City: Winston-Salem
State/Zip: NC 27106
Phone #: (336) 924-1824
Address/Road #: Subdivision:
1999 Hwy 158
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 2
# of People:
*Water Supply: PUBLIC
*IP Issued by: 2140 -Nations, Robert
*CA issued by: 2140 - Nations, Robert
Design Flow: 2 4 0
Soil Application Rate: a 7 5
4Property Owner: Ann Morgan/ CTK Group LLC
Address: 4640 Cherry Hill Lane
City: Winston-Salem
State/Zip: NC 27106
hone #: (336) 924-1824
Phase: Lot:
Directions
Hwy 158 East on left past Jasmine Lane
Nitrification Field 8 7 a Sq. ft.
*System Classification/Description:
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
Saprolite System? O Yes (gNo
*Distribution Type: GRAVITY -SERIAL Pump Re uired?
Q Yes � No
*Pre -Treatment:
No. Drain Lines 5
Total Trench Length: a 1 6 ft.
Trench Spacing: _ 9 Qlnches O.C.
0 Feet O.C.
Trench Width:_ 3 Qlnches
® Feet
Aggregate Depth: inches
Minimum Trench Depth:
Inches
Minimum Soil Cover:
Inches
Maximum Trench Depth:
Inches
Maximum Soil Cover:
\ Inches
Page 1 of 4
*System Type: INFILTRATOR QUICK 4 STANDARD
Installer: Dunn grading Sherman Dunn
Certification #: 2702
*EHS: 2140 - Nations, Robert
Date: 0 6/ a 3/ a 0 1 4
CDP File Number .139140 -1
/ Manufacturer:
STB:
PT:
Gallons:
Gallons:
Date:
Installer:
Date:
Dosing Volume:
*Filter Brand:
Riser Sealed ❑
Yes
❑
No
ST Marker:
❑
Yes
❑
NO
Reinforced Tank:
❑
Yes
❑
NO
1 Piece Tank:
❑YeS
1 Piece Tank: ❑
❑
NO
/ Manufacturer:
PT:
i1equirennent
Gallons:
Installer:
Date:
Dosing Volume:
Riser Sealed ❑
Yes
❑
No
Riser Height: ❑
Yes
❑
No (Min. 6 in.)
Reinforced Tank: ❑
Yes
❑
No
1 Piece Tank: ❑
Yes
❑
No
Countv ID Number:
tic i anK
Lat.
Long:
Installer:
Certification #:
*EHS:
Date:
Supply Line
PipeSize: inch diameter Installer:
Pipe Length: feet Certification #:
*Schedule: *EHS:
Pressure Rated ❑ Yes ❑ No Date:
Approved fittings ❑ Yes ❑ NO ;°' App I StatU
Pump Type:
1 -UMP
i1equirennent
Installer:
Dosing Volume:
-
Gal Certification #:
Draw Down:
Inches
*EHS:
*Chain:
Date:
Valves Accessible
❑
Yes
❑
No
Flow Adjustment Valve
❑
Yes
❑
No
Check -valve
❑
Yes
❑
NOApprovai
Status
PVC Unions
❑Yes
❑
No
[ Approved ❑' Disapproved
Vent Hole
❑
Yes
❑
NO
Anti -siphon Hole
❑Yes
❑
NO
Page 2 of 4
COP File Number 139140 - 1
County ID Number:
NEMA 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
❑
No
*Activation Method:
Date.
Alarm Audible ❑ Yes ❑ No
Alarm Visible ❑ Yes ❑ No
2140 - Nations, Robert
*Operation Permit completed by*
Authorized State Agent: Date of Issue: 0 6/ a 3 / a 0 1 4
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.1 900 et. Seq., and all conditions of the Improvement Permit and
Construction Authorization. This property is served by a TYPE a A. 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: N/A
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency By Certified Operator:
N/A
Reporting Frequency By Certified Operator: N/A
Rule .1961 requires that a Type IV and V septic systems designed for a home/business owner must maintain a valid contract
with a public management entity with a certified operator or a private certified operator for the life of the septic system.
Rule .1961 requires that Type VI septic systems designed for a home/business owner must maintain a valid contract with a
public management entity with 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 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 O Import Drawing
**Site Plan/Drawing attached.**
Page 3 of 4
Drawing Drawing
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC
: Operation Permit
CDP File Number: 139140 - 1
County File Number:
27028 Date: / /
O Inch
Scale: . O Block
Q N/A
C
Page 4 of 4
P1 P2 P3
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: Ann Morgan/ CTK Group LLC
Address: 4640 Cherry Hill Lane
City: Winston-Salem
State/Zip: NC 27106
Phone #: (336) 924-1824
Address/Road #: Subdivision:
1999 Hwy 158
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 2
# of People:
*Water Supply: PUBLIC
PERMIT VALID UNTIL:
0 6/ 1 8/.2 0 1 9
�"Property Owner: Ann Morgan/ CTK Group LLC
Address: 4640 Cherry Hill Lane
City: Winston-Salem
State/Zip: NC 27106
Phone #: (336) 924-1824
Phase
Directions
Hwy 158 East on left past Jasmine Lane
Lot:
Classification:
Provisionally Suitable
Minimum Trench Depth:
a 4
Inches
\Site
Saprolite System?
O Yes (9 No
Minimum Soil Cover:
1 a
Inches
Design Flow:
oZ 4 0
Maximum Trench Depth:
3 6
Inches
Soil Application Rate:
0 .2 7
5
Maximum Soil Cover:
2 4
Inches
*System Classification/Description:
*Distribution Type:
TYPE II A. CONV SYSTEM (SINGLE-FAMILY
OR 480 GPD OR LESS) Septic Tank:
Gallons
*Proposed System: 25% REDUCTION
1 -Piece:
QYes
® No
Pump Required: QYes
0 N
(8) May Be Required
Nitrification Field
8
7
3 Sq. ft. Pump Tank:
1
0 0 0 Gallons
No. Drain Lines
3
1 -Piece:
QYes
ONo
Total Trench Length:
1 8
GPM --vs--
ft. TDH
.2
ft
Trench Spacing:
_
9
OInches O.C.
® Feet O.C. Dosing Volume:
_
Gallons
Trench Width:
3O
Inches
® Feet
_
Grease Trap:
Gallons
Aggregate Depth:
inches
Pre -Treatment: O NSF OTS -1 OTS -11
Septic Tank Installer Grade Level Required: 01
Oil 0111 ON /
Page 1 of 3
CDP File Number 139140-1
Repair Syste
Repair System
*Site Classification:
Design Flow:
Soil Application Rate:
*System Classification/Description:
*Proposed System:
County ID Number:
uired:OYes ONO ONO, but has Available S
Nitrification Field
Sq. ft.
No. Drain Lines
Total Trench Length:
ft.
❑ Open Pump System Sheet
Trench Spacing: O Inches 0.
O Feet O.C.
Trench Width:— Inches
8Feet
Aggregate Depth:
inches
Minimum Trench Depth:
Inches
Minimum Soil Cover:
Inches
Maximum Trench Depth:
Inches
Maximum Soil Cover:
Inches
*Distribution Type:
Pump Required: OYes O No O May Be Required
Pre -Treatment: O NSF OTS -1 OTS -II
*Site Modifications
acbm
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. R
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. Remaining
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 130A336(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? OYes ONO
Applicant/Legal Reps. Signature: Date:
*Issued By: 2140 - Nations, Robert Date of Issue: 0 6 / 1 8 / a 0 1 4
Authorized State Agent: '�j./j on+ Malfunction Log OYes
(9) Hand Drawing O Import 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
r�
U4Z LJ
i,I a- V41 5
CDP File Number: 139140 - 1
County File Number:
Date: 06/ 18 /.2014
O Inch
Scale: O Block
O N/A
1
I
r/
Page 3 of 3
P1 P2
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
CDP File Number: 139140 - 1
County File Number:
Date: .0.6./ 18 / .2 0 14
Click below to import an image from an external location: Drawing Type: Construction Authorization
Page 3 of 3
P1 P2
Davie COUNTY
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
• - 0
TEL: 336-753-6780 FAx:336-753-1680 Request ID: 49087
REQUEST FOR SERVICE/COMPLAINT INVESTIGATION REPORT
REQUEST DATE: 06/18/2014 TAKEN BY: Bonnie
SECTION: N/A TYPE:
PROPERTY NUMBER: 139140 ASSIGNED TO: Nations, Robert
ESTABLISHMENT NUMBER:
PERSON OR PREMISES TO SEE: OWNER: Ann Morgan/ CTK Group LLC
Ann Morgan/ CTK Group LLC 4640 Cherry Hill Lane
1999 Hwy 158 Winston-Salem , 27106
Mocksville NC, 27028
(336) 924-1824
REQUESTED BY: Owner HOME:
WORK:
Cell:
CONDITION REPORTED:Had pumped last year, by Page. Needed something them, but now backing up.
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
Complaintant Contacted: NO
Resolved Date:
Ref1d 16e4f
JIM,aA W —
DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE RZIQUFST
APPLICATION IP/ATC OSWW REPAIR (359Sb- �4(17%
Name-4AIA) d / O/J
v rK AOU L 16 Telephone Number Q' 6?07T
Address I 1qq q as w r
K
Mailing Address (if different from above) -Nein M/% C a 0,6
Email Address:
Subdivision Name
Lot #
Directions —ji5y
/1% 1-e-
Date System Installed
Name System Installed Under
Type Facility lkai-e-
Number Bedrooms_ Number People Served
Type Water Su ply , h f L4�
Specific Problem Occurring >V M,0.0 f /�
r-
Dto Requested
Info Taken By 6 1 1-60
THIS IS TO CERTIFY THAT TH
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
Parcel #: H50000002407
Davie County, NC - Basic Estate Search
Basic Search Real Estate Search Tax Bill Search Sales Search
View Prooertv Record for this Parcel View Mao for this Parcel View Tax Bill Information
Parcel #: H50000002407 Account #: 82528492
Owner Information
Tax Codes
ADVLTAX - COUNTY T
FIREADVLTAX - FIRE TAX
K GROUP LLC
TTN; ANNE BROCK
INSTON SALEM NC 27106
BXF:
Property Information
Township
Land (Units/Type): 0.970 AC
ddress: 1999 US HWY 158
MOCKSVILLE
6
Deferred:
Deed Information
Local Zoning
ate: 07/2007 Book: 00722 Page: 0409
lat Book: Page:
Le al Description
PIN
1.002 AC HWY 158
5749271222
Property Values
Building:
32,03
BXF:
Land:
2Market:
dOl
6sensed•
6
Deferred:
Sales Information
No. Book Page Month Year Instrument Qual/UnQual Improved Price
L 00194 0278 04 1997 WD Unqualified Vacant 37,000
i 00194 0281 04 1997 WD Unqualified Improved 18,000
3 00722 0409 07 2007 WD Unqualified Improved 0
View Property Record for this Parcel View Mao for this Parcel View Tax Bill Information
« Return to Basic Search
Page 1 of 1
vP�r�
01-orja--16
Davie County Web Site
All information on this site is prepared for the inventory of real property found within Davie County. All data is compiled from recorded deeds,
plats, and other public records and data. Users of this data are hereby notified that the aforementioned public information sources should be
consulted for verification of the information. All information contained herein was created for the Davie County's internal use. Davie County,
its employees and agents make no warranty as to the correctness or accuracy of the information set forth on this site whether express or
Implied, in fact or in law, Including without limitation the implied warranties of merchantability and fitness for a particular use.
If you have any questions about the data displayed on this website please contact the Davie County Tax Office at (336) 753-6120.
1.5.9
http4maps.daviecountync.gov/itsnet/View.aspx?prid=1472138 6/8/2016