2239 Hwy 801S OPERATION PERMIT or tficeMe nv
Davie County Health Department *CDP Fite Number 158051 -11
210 Hospital Street G8430-1210-010
P.O. Box 848 County ID Number:
Mocksville NC 27028 Evaluated For. REPAIR
Phone:336-753-6780 Fax:336-753-1680 Township:
Applicant: Paul Melvin Gregory Property owner. Paul Melvin Gregory
Address: 2239 NC Hwy 801 South Address: 2239 NC Hwy 801 South
.Cily: Advance City: Advance
State2ip: NC 27006 StatefZip: NC 27006
Phone#: Phone#:
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
2239 NC Hwy 801 South
Advance NC 27006 Directions
Structure: SINGLE FAMILY Hwy,64 East, left on 801, go approx 4 miles on right
#of Bedrooms: 3
after passing Ellis School
#of People:
"Water Supply: NIA
'IP Issued by. 'System Class ificatan/0escription:
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
'CA issued by: 2140•Nattons,Robert Saprolite System? 0 Yes QNo
Design Flow: 3 6 0Distribution Type: GRAVITY-SERIAL Pump Required?
( Yes QNo
.Soil Application Rate: 0 3 •Pre Treatment:
Drain field
rNo.
cation Field 1 a 0 0 Sq. ft. `System Type: INFILTRATOR QUICK 4 STANDARD
rain Lines 4 Installer: Bean McDaniel
Total Trench Length: 3 0 0 8• Certification#: 1118
Trench Spacing: — 9 Inches O.C.
+ Feet O.C. 'EH S: 2140•Nations,Robert
Trench Width: 3 Inches
Feet Date: 0 7 / 1 3 / 2 0 1 5
Aggregate Depth: inches
Minimum Trench Depth: 3 6
Inches
Minimum Soil Cover. a 4 ApprovalStatus,
Inches
Maximum Trench Depth: 3 6 ®.Approved O Disapproved .{
lnches
Maximum Soil Cover: a 4
Inches
CDP File Number 158051 - 1 Septic Tank County ID Number: G8-130-130.010
Manufacturer. Let.
STB: Long:
Gallons: Installer.
Date: Certification :
.. *EHS:
*Filter Brand:
ST Marker ❑ Yes 11No Date:
Reinforced Tank: El Yes _ ❑ No
R rovat Status
1 Piece Tank: ❑ Yes ❑ No ❑ Approved❑.Disapproved�
Pump Tank
Manufacturer. Installer
PT: Certification#:
Gallons: *EH S:
Date: Date.
RiserSealed ❑ Yes ❑ No
RiserHeight: ❑ Yes ❑ No (Min.6 in.)
Approval Status
Reinforced Tank: ❑ Yes ❑ No ❑ ��ve'dUvisa ;rovedPp
Supply Line
Pipe Size: inch diameter .Installer.
Pie Length: feet Certification#:
*Schedule: *EHS:
Pressure Rated ❑ Yes ❑ No Date:
Approved fittings ❑ Yes El No Approval Status
Approved❑ <Disapprove,
Pump Requirement
Pump Type: Installer
Dosing Volume: — Gal Certification :
Draw Down: Inches *EHS:
*Chain:
Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve ❑ Yes ❑ No Appro)(A atus�
PVC unions ❑ Yes ❑ No ❑'Approved❑ Dlsapprovetl
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole ❑ Yes ❑ No
CDPf File Number 158051 - 1 County ID Number: G8-130.60-010
Electric Equipment
N EMA 4X Box or Equivalent El Yes ElN O Installer,
Box 12 inches Above Grade E] Yes ❑ No
Certification#:
Box Adj.
Pump Tank ❑ Yes ❑ No
Conduit Sealed ❑ Yes ❑ No *EHS:
Pump Manually Operable ❑ Yes ❑ NO
*Activation Method: Date:
Approval Status
Alarm Audible E3 Yes ❑ No ❑ Approved❑ Disapproved
Alarm Visible ❑ Yes ❑ No
=L111
2140-Nations.Robert
*Operation Permit completed by:
Authorized State Agent:. r..—z.�� Date of Issue: 0 3 / 1 3 / a 0 1 5
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 as 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 TYPE II 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:
N/A
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 entitywith a certified operatoror a private certified operator forthe 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 bya 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 tong 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.
GiHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT
Davie County Health Department CDP Fife Number: 158051 - 1
210 Hospital Street G8-130.60-010
P.O.Box 848
County File Number:
Mocksville NC 27028 Date: f /
Q Inch
Drawing Drawing Type: Operation Permit Scale: . ON A k
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CONSTRUCTION For office use only
AUTHORIZATION *CDP File Number 158051 -1
Davie County Health Department County ID Number:
210 Hospital Street Evaluated For: REPAIR
.� ,. P.O.Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 0 9 / 1 6 / 2 0 1 9
F
ant: Paul Melvin Gregory Property Owner. Paul Melvin Gregory
ss: 2239 NC Hwy 801 South Address: 2239 NC Hwy 801 South
City: Advance City: Advance
StatefZip: NC 27006 State2ip: NC 27006
Phone#: Phone#:
Property Location & Site Information
r
ad#: Subdivision: Phase: Lot:
Hwy 801 South
NC 27006 Directions
Structure: SINGLE FAMILY Hwy 64 East, left on 801, go approx 4 miles on right after
#of Bedrooms: 3 passing Ellis School
#of People:
*Water Supply: N/A
System Specifications
Minimum Trench Depth: a 4
Site Classification: Provisionally Suitable Inches
Minimum Soil Cover.
Saprolite System? OYes ONo 1 a Inches
Design 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:
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
Septic Tank:
Gallons
*Proposed System: 25%REDUCTION 1-Piece: OYes ONo
Pump Required: OYes ONo OMay 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 0 ft GPM—vs— ft. TDH
Trench Spacing: _ 9 8 Inches Feet 0 C.0 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: 01 OII 0111 OIV
Pagel of 3
-CDP File Number 158051 - 1 County ID Number: G8-130-130-010
❑ Open Pump System Sheet
Repair System Required:OYes ONo ONo, but has Available Space
rDesign
System
Trench Spacing: Inches O. .
ification: 8 Feet O.C.
Trench Width: Inches
w: _ Feet
Soil Application Rate: Aggregate Depth: inches
*System Classification/Description: Minimum Trench Depth: Inches
Minimum Soil Cover.
Inches
Maximum Trench Depth:
*Proposed System: Inches
Maximum Soil Cover:
Nitrification Field Inches
Sq.ft.
No. Drain Lines *Distribution Type:
Total Trench Length: ft Pump Required: OYes ONo OMay Be Required
PreTreatment: ONSF OTS-1 OTS-II
*Site Modifications
No grading or constriction activity is allowed in areas designated for system and repair without approval of Health Department.
7!
*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. °"•
f..
2(
This Authorization for wastewater System Construction shall be valid Tor a person equal to the period of validity of the Improvement Penult,not
to exceed five years,and may be Issued atthe sametime 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(g)).The person owning or controlling the system shall be responsible for assuring compliance
with the laws,rhes,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 9 1 6 / 2 0 1 4
Authorized State Agent: L Malfunction Log Oyes
OHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
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CONSTRUCTION AUTHORIZATION
Davie County Health Department CDP File Number: 158051 - 1
210 Hospital Street
P.O.Box 848 County File NumbercaG8-130-130-010
Mocksville NC 27028 Date: 09 / 1 6 / a 0 1 a
Q Inch
Drawing Drawing Type: Construction Authorization Scale: . QBlock
QN/A
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