1843 Hwy 64E OPERATION PERMIT" or
Davie County Health Department *CDP File Number 202245-1 ,rte. 210 Hospital Street 5757498372
P.O.Box 848 County ID Number
Mocksville NC 27028 Evaluated For. NEW
Phone:336-753-6780 Fax:336-753-1680 Township:
Applicant: Abee Clearing and Grading Property Owner. Richard G.Allen
Address: 2381 US Hwy 64 W Address: 134 Terrace Lane
CRY: Mocksville City: Mocksville
State/Zip: NC 27028 State0p: NC 27028
Phone#: (336)492-2089 Phone#: (336)926-9787
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
1843 US Hwy 64 E
Mocksville NC 27028 Directions
, 4tructure:
SINGLE FAMILY
Hwy 64 east on left just before Dutchman Creek
k• , Bridge
of Bedrooms: 3
#of People:
*Water supply: PUBLIC
'IP Is
'System Classification/Description:
Issued by.
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPO OR LESS)
*CA issued by: 2140-Nations,Robert
Saprolite System? QYes a No
Design Flow: 3 6 0 *Distribution Type: GRAVITY-SERIAL Pump Required?
QYes (E)No
Soil Application Rate: 0 3 *Pre Treatment:
Drain field
rNoarnifimition Field 1 2 0 0 Sq.ft. *System Type: BIODIFFUSERARC36
ain Lines 3 Installer: Tim Abe$
Total Trench Length: 3 0 0 ft. Certification#: i101
Trench Spacing: — 9 Inches O.C.
• Feet O.C. 'EH S: 2140-Nations.Robert
Trench Width: — 3 Olnches
Date: 0 8 / 1 0 / 2 0 1 6
Aggregate Depth: inches
Minimum Trench Depth: 3 6
Inches
Minimum Soil Cover. 4 Approval Status
Inches :
Maximum Trench Depth 6 Inches ®aApproVedOYDlSapproved,
Maximum Soil Cover: 2 4 Inches
}
CDP File Number 202245- 'I County ID Number: 5757498372
Septic Tank
Manufacturer. Shoat Lat.
STB: 760 Long:
Gallons: 1000
Installer Tim Atee
Certification#: 1011
Date: 0 5 / 0 7 / a 0 1 6
'EHS: 2140-Nations,Robert
"FiiterBrand: POLYLOKPLA 22 With Pipe Adapter
ST Marker: 1:1 Yes R NO
Date: 0 8 / 1 0 / 2 0 1 6
Reinforced Tank: ❑ Yes ® NO Approval Status
1Piece Tank: Yes No❑
Approved❑ sapproved
Pump Tank
Manufacturer. Installer
PT: Certification#:
Gallons: 'EH S:
Date: / i Date:
RiserSealed ❑ Yes ❑ No
RiserHeght: ❑ Yes ❑ No (Min.6 in.) Approval Status
Reinforced Tank: El Yes O No =❑ Approved❑ Disapproved,
1 Piece Tank: ❑ YeS ❑ NO <.
Supply Line
CPoe Size: inch diameter Installer.
Pipe Length: feet Certification :
"Schedule: 'EH S:
Pressure Rated ❑ Yes ❑ No Date.
Approved fittings [I Yes. ❑ No Approval Status
❑ Approved❑ Disapprove
t
Pump
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 ElN o Approval yStatusr.
PVC unions E] Yes ❑ No ❑ Approved❑ Disapproved
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole El Yes ❑ NO
• CDP File Number 202245 - 1 County ID Number: 5757498372
Electric Equipment
NEMA4XBoxorEquivalent ❑ Yes ❑ No Installer:
Bax 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 ❑ Yes ❑ No
_ � Approved❑ Disapproved
Alarm Visible. . ..❑ �es ❑�Wo
2140•Nations,Robert
*Operation Permit completed by:
Authorized State Age Date of Issue: 0 8 1 0 / 2 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 It A. sewage septic system.
Rule-A 961 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 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 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 homelbusiness 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 bye 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 41mport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT 242245- 'i
Davie County Health Department CDP File Number:
210 Hospital Street 5757498372
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: / i
Olnch
Drawing Draw( O
ng Type: Operation Permit Scale: , ON A k ft.
_.
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< CONSTRUCTION For office Use only
AUTHORIZATION •CDP File Number 202245-1
.04.-�"`' Davie County Health Department County ID Number.5757498372
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 / a 7 / a 0 a 1
Applicant: Abee Clearing and Grading Property Owner: Richard G.Allen
Address: 2381 US Hwy 64 W Address: 134 Terrace Lane
City: Mocksville City: Mocksville
State2ip: NC 27028 State/Zip: NC 27028
Phone#: (336)492-2089"
9Phone#: (336)926-9787
Property Location & Site Information
rAddress/Road;9: Subdivision: Phase: Lot:
Hwy 64 E
e NC 27028 Directions
Structure: SINGLE FAMILY Hwy 64 east on left just before Dutchman Creek Bridge
#of Bedrooms: 3
#of People:
*Water Supply: PUBLIC
System Specifications
CF1owMinimum Trench Depth:
:
Provisionally Suitable a 4 Inches
Minimum Soil Cover. 1 a
OYes @No Inches
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-SERIAL
TYPE IIA CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
1 0 0 0 _ Gallons
"Proposed System: 25%REDUCTION 1-Piece: OYes ®No
Pump Required: OYes ®No O May Be Required
Nitrification Field 1 2 0 0
Sq. ft. Pump Tank: Gallons
No. Drain Lines 3 1-Piece: OYes ONo
Total Trench Length: 3 0 0 ft GPM vs— ft. TDH
Trench Spacing: _ 9 OnchesFeet O.C. g O.C. Dosin Volume: _ Gallons
Trench Width: Inches
3 _ Feet Grease Trap: Gallons
Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-II
Septic Tank InstallerGrade Level Required: 01011 0111 OIV
Da^o I ^F Q
CDP File Number 202245- 1 County ID Number. 5757498372 y
❑ Open Pump System Sheet
Repair System Required:@Yes ONo ONO, but has Available Space
epair System
Trench Spacing: 9 Olnches O.0
*Site Classification: Provisionally Suitable a Feet O.C.
Trench Width: Inches
Design Flow: 3 6 0 — , 3 Feet
Soil Application Rate: Aggregate Depth:
� - 3 inches
Minimum Trench Depth: a 4
*System Classification/Description: Inches
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. 1 a Inches
*Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches
Nitrification Field 1 2 0
Sq.ft. Maximum Soil Cover a 4 Inches
No. Drain Lines 3 *Distribution Type: GRAVITY-SERIAL
Total Trench Length: 3 0 0 �_ --- Pump Required: QYes QNo OMay Be Required
Pre Treatment: ONSF OTS-I OTS-II
*Site Modifications
No grading orconstruction activityis 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 be valid fora person equal to the period of wlidity of the Improvement Permit,not
to exceed five years,and may be Issued atthe sametime the Improvement Permit issued(NCGS 130A-336(15)).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(8)).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 4 / `a 7 / a 0 1 6
Authorized State Agent: Malfunction Log QYes i
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
{ CONSTRUCTION AUTHORIZATION
Davie County Health Department CDP File Number: 202245- 1
210 Hospital Street 5757498372
P.O.Box 848
County File Number:
Mocksville NC 27028 Date: 0 4 / 2 7 / 0 1 6
0Inch
Drawing Drawing Type: Construction Authorization Scale: , QBlock
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CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street CDP File Number: 202245- 1
P.O.Box 848 5757498372
Mocksville NC 27028 County File Number:
Date: .0 .4 / .1 7 / 2016
Click below to Import an Image from an external location: Drawing Type:Construction Authorization
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APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT&ATC
Davie County Environmental Health
P.O.Boz 8481210 Hospital Street
D ; Mocksville,NC 27028
(336)753-6780/Fax(336)753-1680
Application For: X Site Evaluation/improvement Permit Yi Authorization To Construct(ATC) 0 Both
Type of Application: ONew System ❑Repair to Existing System l7Expansion/Modification of Existing System or Facility
IMPORTANT"'THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed Contact Person
Billing Address fl/ U_S {�UAt o t/ `� Home Phone�1�
City/State/ZIP -MaCk -Aylel 2VG -2-M—IX Business Phone 1704(-a 3,5-,3ioa-7
Name on Permit/ATC. Dent than bove
Mailing Address f R City/State/Zip a aJ
PROPERTY INFORMATION *Date House/Facility Corners Flagged
NOTE: A survey plat or site plan must accompany this application. Included:A Site Plan OPlat(to scale)
(Permit- valid for W months with site plan,no expiration with complete plat.) i
Owner's Name--A�-irhaM :2 Allen Phone Number In Sow—97d'
Owner's Addres� City/State/Zip,AA Asvi I l e AI G
Property Address�g 3 E Wu le U F City Ad ackS-M Imo_
Lot Size e.S�Z 6tG Tax PIN# ` '/_5�'7 . 98•_37 Q-
Subdivision Name(if applicable) Section/Lot#
Directions To Site: (tel( E,
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? E]YesElio
Does the site contain jurisdictional wetlands? ❑Yes?R0
Are there any easements or right-of-ways on the site? Klyes ONo
Is the site subject to approval by another public agency? p�'es ONo
Will wastewater other than domestic sewage be generated? OYes IK6
IF RESIDENC FILL OUT THE BOX BELOW
#People #Bedrooms #Bathrooms Garden Tub/Whirlpool Oyes _ o
Basement: YesWo Basement Plumbing: CYes ATIo
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: ❑ConventionalAccepted 01nnovative OAltema6ve EOther
Water Supply Type:xCounty/CityWater 0 New Well CExisling Well 0 Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve?0 Yes O No
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 permit(s)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 rules. I understand that I am responsible for the proper identification and labeling of property lines and comers and
ocati and flagging or stak�in e houselfacility location,proposed well location and the location of any other amenities.
Site Revisit Charge
Property owner's or owner's legal representative signature
Date(s):
I Lo Client Notification Date:
D e EHS:
Sign given CYes ONo Account# v
Revised 11/06 Invoice# ��( "" /
A�/en
U-S 44wV bq e
M6CI SVII tee l�G
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Sepbc)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Pbg&
t
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring / Pit Cut
FACTORS 1 2 3 4 51 6. •7
Landscape position (/
Slope%
HORIZON I DEPTH _ :'—Texture group C� 61—
Consistence S
Structure 5
Mineralogy Y
HORIZON H DEPTH
Texture group
Consistence
Structure' -
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: D OTHER(S)PRESENT:
REMARKS:
LEGEND
Landscape Position
R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope
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 L SIC-Silty clay C-Clay
CONSISTENCE
a'IQist _
VFR Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky
NP-Non plastic SP-Slightly plastic P Plastic VP-Very.plastic
Structure
SC-Single grain M-Massive CR-Crumb GR-Granular ABK Angular blocky
SBK Subangular blocky PL-Platy PR-Prismatic
Mineralogy
1:1,2:1,Mixed
LYQtr� .
Horizon depth-In inches -
Depth of fill-In inches
Restrictive horizon-Thickness and inches from land surface
Saprolite-S(suitable),U(unsuitable)
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(provisionally suitable),U(unsuitable)
LTAR-Long-term accemtance rate-eal/dav/fU ru■un nvnc M-.—AN