4755 Hwy 158 OPERATION PERMIT or fice,use unIV
Davie County Health Department *COP File Number 158415 1
r � 210 Hospital Street DM0.00165-01
P.O. Box 848 County ID Number:
Mocksville NO 27028 Evaluated For. NEW
Phone:336-753-6780 Fax:336-753-1680 Township:
FApplicant: Jeffrey A Newman Property owner. Jeffrey A Newman
Address: 4755 US Hwy 158 Address: 4755 US Hwy 158
City: Advance CRY: Advance
State/Zip: NC 27006 StaterZip: NC 27006
Phone#: (336)998-7743 Phone#: (336)998-7743
Property Locatlon & Site Information
Address/Road Subdivision: Phase: Lot:
4755 US Hwy 158
Advance NC 27006 Directions
Structure: SINGLE FAMILY Hwy.158 East across from Gun Club Rd
#of Bedrooms: 4
#of People:
*Water Supply: PUBLIC
*IP Issued by: 21ao-Nations,Robert 'System Classification/Description:
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by: 2140-Nations,Robert
Saprolite System? ( Yes QNo
Design Flow: 3 6 0 GRAVITY-PARALLEL d-box Pump Required?
Distribution Type: Com' )
()Yes QNo
Soil Application Rate: 0 3
*Pre Treatment:
Drain field
rNirificnation Field 1 2 0 0 Sq•ft. *System Type: INFILTRATOR QUICK 4 STANDARD
n Lines 3 Installer: Marty Cater
Total Trench Length: 3 0 0 ft. Certification#: 3027
Trench Spacing: — Inches O.C.
Feet O.C. *EH S: 2140-Nations,Robert
Trench Width: 3lnches
Feet Date: 0 6 / 0 2 / 2 0 1 6
Aggregate Depth: inches
Minimum Trench Depth: 3 6
Inches
Minimum Soil Cover. a 4 Approval'yStatus ,
Inches r
Maximum Trench Depth: 3 6 Inches ® Approved Disapproved
Maximum Soil Cover: a 4
Inches
CDP File Number 158415 - I County ID Number: 137-000.0016"ll
Septic Tank
Manufacturer. shoaf Lat.
Long: .
STB: 7&0 _
Installer. Marty Carter
Gallons: Sapp
Certification#: 3027
Date: 0 a / a 9 / x 0 1 6
*ENS: 2144•Nations,Robert
'Fitter Brand: POLYLOK PL-122 With Pipe Adapter
Date: e 6 / 0 a / a 0 1 6
ST Marker. ❑ Yes ® No -
Reinforced Tank: ❑ Yes E No Approval Status
� Piece Tank: ❑ Yes Cl No - � Approved❑ =Disapproved
Pump Tank
Manufacturer. Installer.
PT: Certification#:
Gallons: 'EHS:
Date: / / Date:
RiserSealed ❑ Yes ❑ No
RiserHeight: ❑ Yes ❑ No (Min.6 in.)
Approval Status
Reinforced Tank: ❑ Yes ❑ No ❑ Approved❑.f7d
1 Piece Tank: ❑ Yes ❑ No
Supply Line
CPipe Size: inch diameter Installer.
Pipe Length: feet Certification#:
'Schedule: 'EHS:
Pressure Rated ❑ Yes ❑ No Date: I I
Approved fittings ❑ Yes ❑ No ApprovalStatus
❑ Approved❑ Dis
approvetl
Pump
Pump Type: Installer
Dosing Volume: — Gal Certification#:
Draw Down: Inches *EH S:
*Chain: I I
Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ NO
Check-valve ❑ Yes ❑ NO gpproval'Status� ,
PVC Unions El Yes ❑ No = ❑ Approved O Dls'approved
Vent Hale ❑ Yes ❑ No
Anti-siphon Hole ❑ Yes 0 No
CDP File Number 158415 - 1 County ID Number: °7'000-00165-01
Electric Equipment
N�4X or Equivalent ❑ Yes ❑ No Installer:
Box 12 inches Above Grade ❑ Yes ❑ No
Certification#:
Box Adj.To Pump Tank ❑ Yes ❑ No
Conduit Sealed ❑ Yes ❑ No *ENS:
Pump Manually Operable ❑ Yes ❑ No'
*Activation Method: Date:
Approval Stafus;
Alarm Audible ❑ Yes ❑ No
Approved❑ Disapproved
Alarm Visible ❑ Yes ❑ No
2140-Nations,Robert
*Operation Permit completed by:
Authorized State Agent: Date of Issue. 0 6 / 0 a / 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 Disposal, 15A NCAC 18A.1900 et. Seq.,and all conditions of the Improvement Permit and
Construction Authorization.This property is served by a TYPE II A. sewage septic system.
Rule.1961 requires that a Type TYPEIM A- septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: N/A
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency By Certified Operator.
NIA
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 entitywth a certified operator or a private certified operator for the 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 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 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.
O Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.** '`
OPERATION PERMIT 158415- 1
Davie County Health Department CDP File Number:
210 Hospital Street D7-000.00165.01 ,
P.O.Box W County File Number:
Mocksville NC 27028 Date:
O Inch
Drawing Drawing Type: Operation Permit Scale: . Oelock = ft.
oN�
I
45>-
T7--L-1
I T
T-1 I I I
i
I S I EE I i I
I
CONSTRUCTION For office Use only
AUTHORIZATION *CDP File Number ,158415-1
Davie County Health Department County ID Number:
D7
Davie
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 0 4 I 3 0 I a 0 0
Applicant: Jeffrey A NewmanProperty Owner: Jeffrey A Newman
Address: 4755 US Hwy 158 Address: 4755 US Hwy 158
City: Advance City: Advance
State/Zip: NC 27006 State/Zip: NC 27006
Phone#: �336,�998-77�43 ..� Phone#: (336)998-7743
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
4755 US Hwy 158
Advance NC 27006 Directions
Structure: SINGLE FAMILY Hwy 158 East across from Gun Club Rd
#of Bedrooms: 4
#of People:
*Water Supply: PUBLIC
System Specifications
Minimum Trench Depth: a 4
(Design
e Classification: Provisionally Suitable Inches
Minimum Soil Cover: 1 a
rolite System? OYes 9 No Inches
Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 3 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) Septic Tank: 1 0 0 0
Gallons
*Proposed System: 25%REDUCTION 1-Piece: O Yes ®No
Pump Required: OYes ®No O May Be Required
Nitrification Field 1 a 0 0
Sq.ft. Pump Tank: Gallons
No. Drain Lines 4 1-Piece: OYes ONo
Total Trench Length: 3 0 0GPM—vs-- ft. TDH
ft.
Trench Spacing: OInches O.C.
_ _
9 ®Feet O.C. Dosing Volume: Gallons
Trench Width: 3 Inches
Feet Grease Trap: Gallons
Aggregate Depth:
inches Pre-Treatment: ONSF OTS-1 OTS-II
Septic Tank Installer Grade Level Required: 01011 O III 01V
Page 1 of 3
CDP File Number 158415 - 1 County ID Number: D7-000-00165-01
❑ Open Pump System Sheet
Repair System Required:0 Yes O No ONO, but has Available Space
CDesign
System
Trench Spacing: 8 O Inches O.C.
fication: Provisionally suitable — ®Feet O.C.
Trench Width: O Inches
w: 3 6 0 — ®Feet
Soil Application Rate: 0 3 Aggregate Depth: inches
.___.
*System Classification/Description: Minimum Trench Depth: a 4 Inches
TYPE III E.PPBPS GRAVITY DOSED SYSTEM Minimum Soil Cover: 1 a
Inches
Maximum Trench Depth: 3 6 Inches
*Proposed System: 50%REDUCTION
Maximum Soil Cover: � 4
Nitrification Field 1 a 0 0 Inches
Sq.ft.
No.Drain Lines 4 *Distribution Type: GRAVITY-PARALLEL(eq.d-box)
Total Trench Length: a 0 0 ft. Pump Required: OYes ®No OMay 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. R m"a v
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. Rwwftm
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(9)).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 4 / 3 0 / a 0 1 5
Authorized State Ager1'; � Malfunction Log OYes
Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION 158415 - 1
Davie County Health Department CDP File Number:
210 Hospital Street D7-000-00165-01
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 04 / 30 / ,2015
Q Inch
Drawing Drawing Type: Construction Authorization Scale: , 00 Block
�OAJ
r
,Q
1
O
a1 1104
Li
Page 3 of 3
P1 P2
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital street CDP File Number: 158415 - 1
P.O.Box 848 D7-000-00165-01
Mocksville NC 27028
County File Number:
Date: .0.4./.3.0 /.2 0 1.5.
Click below to import an image from an external location: Drawing Type: Construction Authorization
Page 3 of 3
P1 P2
-IMPROVEMENT PERMIT For Office Use Only
'CDP File Number 158415- 1
Davie County Health Department
-~ County ID Number:D7-000-00165-01
I0' 210 Hospital Street PAID
P.O. Box 848 Date; "� Evaluated For: NEW
Mocksville tved b ; Township:
Phone:336-753-6780 Fax:336-753-1680
PERMIT VALID UNTIL 1019!2019
"NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit.
Applicant: Jeffrey A Newman Property owner: Jeffrey A Newman
Address: 4755 US Hwy 158 Address: 4755 US Hwy 158
City: Advance CRY: Advance
State2ip: NC 27006 StatelZip: NC 27006
Phone#: (336) 998-7743 Phone#: (336)998-7743
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
4755 US Hwy 158
Advance NC 27006 Directions
Structure: SINGLE FAMILY Hwy 158 East-across from Gun Club Rd
#of Bedrooms: 3 1 of 1511q PtQ. Rab
#of People:
'Water Supply: PUBLIC
Initial System Specifications
ss Slrstem
'Site assassl"fica an: Provisionally suitable
Minimum Trench Depth: a 4 Inches
Saprolite System? Oyes QNo
_ Maximum Trench Depth: _ 3 6 _ Inches
Design Flow: 3 6 0 Septic Tank: 1 0 0 0
Gallons
Soil Application Rate: 0 3 1-Piece: OYes @No
Pump Required: OYes (D No OMay Be Required
'System Classification/Description:
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons
LESS)
'Proposed System: 25%REDUCTION 1-Piece: OYes ONo
Repair System Required:OYes ONo ONo, but has Available Space
Repair System
"Site Classification: Provisionally Suitable Minimum Trench Depth: a 4 Inches
Soil Application Rate: 0 - a a 5 Maximum Trench Depth: 3 6 Inches
'System Classification/Description: Pump Required: OYes O No O Maybe Required
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR
LESS)
'Proposed System: 25%REDUCTION
Pagel of 3
CDP File Number iots4 10 - 'l County ID Number: ""-"u"-""'00-u#
*Site Modifications ❑ Open Fill Sheet
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
. 1
*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. ct
7
Site Plan The Improvement Permit shall be valid for 5 years from date of issue with a site plan(means a drawing not necessarily drawn to
scale that shows the existing and proposed property lines with dimensions,the location of thefacility and appurtenances,the
O
G site for the proposed Wastewater system,and the location of water supplies and surfacewaters).
Plat The Improvement Permit shall be valid without expiration with plat(means a property surveyed prepared by a registered land
O surveyor,drawn to a scale of one Inch equals no m ore than 60 feet,that Includes:the specific location of the proposed facility
and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters. Plat
also means,for subdivision lots approved by the local planning authority and recorded with the county 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 Issuance and 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(NCGS 130A-335(f)).The person owning orcontrolling the system shall be responsible forassuring 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: 1 0 / 0 9 / 2 0 1 4
Authorized State Agent: OValid without Expiration?
O Create CA?
OHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
Davie County Health Department CDP File Number: 158415 - 1
210 Hospital Street D7-000-00165-01
P.O.Box 848 County File Number:
Mocksville NC 27028 Date:
Qlnch
Drawing Drawing Type: Improvement Permit Scale: QBlock
ON/A ft.
'NJ:
n
s _
�a
1
m
L
y: JL CWQ
Page 3 otf 3�.,►y
.r _
PLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT&
Q,Cj _ ,, ___,Davie County Environmental Health �.:_ q Pa�t
ep�
1 .`� P.O.Box 848/210 Hospital Street
Mocksville,NC 27 28
(336)753-6780/Fax 336 k-1680 �� Q
Application For: ❑Site Evaluation/Improvement Permit 'za io o Construct(ATC) ❑Both
Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
•"1MM9ORTAN7***THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed .� (! Ig�I�S'GJ M,r4/U Contact Person a MAN
Billing Address !/!7.13 —U.S. Hr&Y 158 Home Phone 3
City/State/ZIP 1tDVo1M0Z 14.L*. Z'iOob Business Phone �n
Name on Permit/ATC if Different than Above
Mailing Address City/State2ip
PROPERTY INFORMATION *Date House/Facility Comers Flagged
NOTE: A survey plat or site plan must accompany this application. Included:RrSite Plan ❑Plat(to scale)
(Permit is valid for 60 months with site plan,no expiration with complete plat)
Owner's Name Ik M AM Phone Number o'08—7`7 crS
Owner's Address .5 S 8 —City/State/Zip I�Ot[AIUL°S nl.L�•
Property Address . R . Ci
Lot Size Tax PIN#'bCP o -O
Subdivision Name(if applicable Section/Lot#
Directions To Site: 0A( a Ly A e-D D �
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 JdNo
Does the site contain jurisdictional wetlands? ❑Yesa'Ro
Are there any easements or right-of-ways on the site? []Yes Jallo
Is the site subject to approval by another public agency? ❑Yes RNO
Will wastewater other than domestic sewage be generated? ❑YesANo
IF RESIDENCE FILL OUT THE BOX BELOW
#People I #Bedrooms d— #Bathrooms 3 Garden Tub/Whirlpool❑Yes,BNo
Basement:ZYes ❑No Basement Plumbing: ❑Yes ZNo
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business Total Square Footage of Building #People
#Sinks #Commodes #Showers #Urinals
Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: #Seats
Type system requested:)conventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type-/County/City Water ❑New Well Misting Well ❑Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve?❑Yes eNo
If yes,what type?
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand
that any permits)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use
changes,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 comers and
loc rg d flaggi or ting the house/facility location,proposed well location and the location of any other amenities.
Site Revisit Charge
Pr pV-1-141
's or o islegal representative signature
Date(s):
Client
Notification Date:
Date EHS`
Sign given ❑Yes❑No Account# � '
Revised 11/06 Invoice# --c �
l . •
147S,S To .3,15- Z)-,woL SH-D
VL
t S
Xp,
.Q
3
s
r•
789
t
1
5
I
i
LO 5
1,
(4.1OA) It u.
6615 �� 2
S
1
t"S �
f? m 1
x I
' 3 7 1
i
la 9725
7 509 „6579
7595
77
547
a 5 l
N
472
4311 1
Printed:Sep 18, 2014
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 of the use or
inability to use the GIS data provided by this website.
I DAVIE COUNTY HEALTH DEPAR NT
Environmental Health Section
Soil/Site Evaluation
AP LI A T=RMK JONTax PIN/EH#: ID7-00 - INFORMATION
ccoun . 90006 119
. Billed To: Jeffrey N wman Subdivision Info:
Reference Name: Location/Address: r755 US wy 158-27028
Proposed Facility: ResidencProperty Size: Da Evalua d: ( U — 3 _
l '
i
Water Supply: On- ite Well Community blic
Evaluation By: Aug r Boring Pit ut
FACTORS j 1 2 3 �} 5 6 7 i
Landscape position L I Lr L I
Slope % -L
HORIZON I DEPTH _ 17
_ }
Texture group S G4, 5 G L
Consistence i }
Structure a GR 0
Mineralogy _ }
HORIZON II DEPTH — }
Texture group G SG G( }
j Consistence { f Sf S 5 v , .., I
Structure koF kS J }
Mineralogy
HORIZON III DEPTH r }
Texture group ! }
Consistence } {
Structure ± ( }
j
Mineralogya }
i HORIZON IV DEPTH j
Texture group
Consistence ! }
Structure
MineralogyI j
SOIL WETNESS }
RESTRICTIVE HORIZON }
SAPROLITE 1 I I
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE S }
SITE CLASSIFICATION: EVALUATI N BY: 11a1yj161_C:;'
( LONG-TERM ACCEPTANC 'RATE: ��Z3 OTHERS)PRESENT:
REMARKS: oni
LEGEND 4�
Landscape Position ' f
R-Ridge S -Shoulder ' L-Linear slope FS -Foot slope N-Nose slope,
CC-Concave slope CV-�onvex slope T-Terrace FP-Flood plain Hi-Head slo
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 }
fCONSISTEN
.
Moist CE
VFR-Very friable . FR-Ffiable FI-Firm VFI-Very firm EFI-Extremely fain
f_ lyd ! f
NS-Non sticky SS-Slig6tly sticky S-Sticky VS-Very Sticky f
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
Structure
SC-Single grain M-Mal'sive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralogy
1:1,2:1,Mixed
Notes
Horizon depth-In inches
Depth of fill-In inches i
Restrictive horizon-Thickness and inches from land surface
Saprolite-S( able),U(unsu�'table)
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 rovisionally suitable),U(unsuitable)
'i TTATI