181 Boger RdOPERATION PERMIT
Davie County Health Department
° ¢ 210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Steve Shepard
Address: 181 Boger Road
City: Mocksville
State/Zip: NC 27028
Phone #: (336) 830-9173
Property Loca
Address/Road #: Subdivision:
181 Boger Rd
Mocksville NC 27028
Structure: OTHER
# of Bedrooms:
# of People:
*Water Supply: EXISTING WELL
*IP Issued by:
*CA Issued by: 2325 - Mitchell, Brittany
Design Flow: 3 6 0
Soil Application Rate: 0 a 5
Nitrification Field
*CDP File Number 198628 - 1
County ID Number:
Evaluated For: REPAIR
�ownship:
//Property Owner: Steve Shepard
Address: 181 Boger Road
City: Mocksville
State/Zip: NC 27028
hone #: (336) 830-9173
ion & Site Information
Phase:
Lot:
Hwy 158 left on Boger Road 1/2 mile down on left
*System Classification/Description:
TYPE III G. OTHER NON-CONV. TRENCH SYSTEMS
Saprolite System? '.,Yes X, No
*Distribution Type: GRAVITY -SERIAL Pump Required?
0 Yes X No
*Pre -Treatment:
Drain field
Sq. ft.
No. Drain Lines 3
Total Trench Length: 3 6 0 ft.
Trench Spacing: _ 9 0Inches O.C.
®Feet O.C.
Trench Width:_ 3 6 (g Inches
0 Feet
Aggregate Depth: inches
Minimum Trench Depth:
3
6
Inches
Minimum Soil Cover:
a
4
Inches
Maximum Trench Depth:
3
6
Inches
Maximum Soil Cover:
\
)
4
Inches
Page 1 of 4
*System Type: INFILTRATOR QUICK STANDARD
Installer: Jamie Barnes
Certification #: 10181
*EHS: 2325 - Mitchell, Brittany
Date: 0 5/ 1 1/.1 0 1 7
Approval Status
0 Approved ❑ Disapproved
CDP File Number 198628 - 1
County ID Number:
Manufacturer:
PT:
se tic i anK
Gallons:
Manufacturer:
Existing
Jamie Barnes
Lat.
❑ Yes
Riser Height:
❑ Yes
Reinforced Tank:
Long:
\ 1 Piece Tank:
STB:
*Schedule: 40
Inches
*EHS:
Pressure Rated ❑ Yes
❑ No
Date:
Installer:
Jamie Barnes
Gallons:
Approval Status
❑X
Approved ❑ Disapproved
Certification #:
10181
Date:
❑
Yes
❑
No
Flow Adjustment Valve
*EHS:
Yes
*Filter Brand:
No
Check -valve
❑
Yes
❑
NO
ST Marker:
❑ Yes
❑ NO
Date:
❑
Reinforced Tank:
❑ Yes
❑ NO
Vent Hole
Approval Status
Yes
❑
NO
El
Approved El Disapproved
1 Piece Tank:
El Yes
El NO
❑
No
Manufacturer:
PT:
Gallons:
inch diameter
Date:
Jamie Barnes
Riser Sealed
❑ Yes
Riser Height:
❑ Yes
Reinforced Tank:
❑ Yes
\ 1 Piece Tank:
❑ Yes
❑ No
❑ No (Min. 6 in.)
❑ No
❑ No
Pump Tank
Installer: Jamie Barnes
Certification #: 10181
*EHS:
Date:
Approval Status
❑ Approved ❑ Disapproved
/ Pump Type:
Supply Line
Pipe Size: 4
inch diameter
Installer:
Jamie Barnes
Pipe Length: 3
5 feet
Certification #:
10181
Gal Certification #:
10181
*EHS:
2325 - Mitchell, Brittany
*Schedule: 40
Inches
*EHS:
Pressure Rated ❑ Yes
❑ No
Date:
5 / 1 1 / a 0 1 7
Approved fittings ❑ Yes
❑ No
Approval Status
❑X
Approved ❑ Disapproved
Date:
Valves Accessible
/ Pump Type:
Installer:
Jamie Barnes
Dosing Volume:
-
Gal Certification #:
10181
Draw Down:
Inches
*EHS:
*Chain:
Date:
Valves Accessible
❑
Yes
❑
No
Flow Adjustment Valve
❑
Yes
❑
No
Check -valve
❑
Yes
❑
NO
Approval Status
PVC unions
❑
Yes
❑
No
❑
Approved ❑ Disapproved
Vent Hole
❑
Yes
❑
NO
Anti -siphon Hole
❑
Yes
❑
No
Page 2 of 4
CDP File Number 198628 - 1
County ID Number:
NEMA 4X Box or Equivalent
❑
Yes
❑
NO
Installer:
Jamie Barnes
Box 12 inches Above Grade
❑
Yes
❑
NO
10181
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
ElNo
❑Approved
❑ Disapproved
Alarm Visible
El
Yes
ElNO
2325 - Mitchell, Brittany
*Operation Permit completed by:
Authorized State Agent: Date of Issue: 0 5/ 1 1/.1 0 1 7
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 111 G. sewage septic system.
Rule .1961 requires that a Type TYPE 111 G. 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.
9 Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 3of4
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC
Drawing Drawing Type: Operation Permit
CDP File Number: 198628 - 1
County File Number:
27028 Date: / /
O Inch
Scale: O Block
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Page 4 of 4 P1 P2 P3
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC
CDP File Number:
27028 County File Number:
Date:. . /
Click below to import an image from an external location: Drawing Type: Operation Permit
Page 4 of 4 P1 P2 P3
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Septic Tank:
Pump Tank:
Supply Line:
Pump Requirements:
Electrical Equipment:
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