2255 Hwy 801S• OPERATION PERMIT
Davie County Health Department
t� 210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Dwight Jackson
Address: 2255 NC Hwy 801 S
Cay Advance
State2ip: NC 27006
Phone #: (336) 998-5357
P
Address/Road #: Subdivision:
f
2255 NC Hwy 801_ S
Advance NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 2
# of People:
'Water Supply: PUBLIC
'IP Issued by. 2244 - Daywalt, Andrew
'CA issued by: 2244 - Daywall, Andrew
Design Flow: 2 4 0
Soil Application Rate: 0 3
'CDP File Number 122016-1
Gb-130.130.012
County ID Number:
Evaluated For: REPAIR
ownship:
Property Owner: Dwight Jackson
Address: 2255 NC Hwy 801 S
Cay Advance
State/Zip: NC 27006
Phone #: (336) 998-5357
ite Information
Phase: Lot:
Directions
Hwy 64 E right on 801 to Advance pass Ellis School
3rd on right
'System Classification/Description:
TYPE 11 A. CONV. SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
Saprolite System? OYes QNo
'Distribution Type: GRAVITY -SERIAL Pump Required?
()Yes QNo
'Pre -Treatment: NIA
Drain field
Nitrification Field
S4' n'
No. Drain Lines
Total Trench Length:
1 0 0 ft.
Trench Spacing:
Qlnches
O.C.
— ()Feet
O.C.
Inches
Trench Width:
—
Feet
Aggregate Depth:
inches
Minimum Trench Depth: 2
4
Inches
Minimum Soil Cover.
Inches
Maximum Trench Depth:
Inches
M ximum Soil Cover:
Inches
'System Type: INFILTRATOR QUICK 4 STANDARD
Installer: buck cleary
Certification #:
'EH S: 2244 - Daywall, Andrew
Date: 0 6/ 2 5/ 2 0 1 3
Approval Status
O Approved ❑ Disapproved
CDP File Number 122016 -1 County ID Number: Gb-130-80-012
Septic Tank
Manufacturer. Lat. - a
Manufacturer.
PT:
Gallons:
Date:
/
/
Long:
,
STB:
No
Riser Height: ❑
Yes
❑
No (Min.6 in.)
Gallons:
Yes
❑
No
Installer:
Yes
Date:
/
/
Certification #:
*EHS:
*Filter Brand:
ST Marker:
❑ Yes
❑
No
Date:
nforced Tank:
❑ Yes
❑
No
Approval Status
❑
Approved El Disapproved
1 Piece Tank:
E3 Yes
El
No
Pump Tank
Manufacturer.
PT:
Gallons:
Date:
/
/
Riser Seated ❑
Yes
❑
No
Riser Height: ❑
Yes
❑
No (Min.6 in.)
Reinforced Tank: ❑
Yes
❑
No
,,-,,,piece Tank: ❑
Yes
❑
NO
Pipe Size: inch diameter
Pipe Length: feet
*Schedule:
Pressure Rated ❑ Yes ❑ No
4pproved fittings ❑ Yes ❑ NO
Installer:
Certification #:
*EH S:
Date:
Approval Status
❑ Approved ❑ Disapproved
supply Line
Installer:
Certification #:
*EHS:
Date:
Approval Status
❑ Approved ❑ Disapproved
(Pump Type: Installer:
Dosing Volume: — Gal Certification K:
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 0 NO
CDP File Number 122016-1
County ID Number: Gb-130-B0-012
2244 - Daywalt, Andrew
'Operation Permit completed by,
Authorized State Agen
Date of Issue: 0 6/ 2 5/ 2 0 1 3
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 11 A. sewage septic system.
Rule .1961 requires that a Type TYPE 11 A. septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: N/A
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency ByCeitifiied Operator:
NIA
Reporting Frequency By Certified Operator: NIA
Rule .1961 requires that a Type IV and V septic systems designed for a homelbusiness owner must maintain a valid contract
with a public management entity with a certified operator or a private certified operator forthe life of the septic system.
Rule .1961 requires that Type VI septic systems designed fora homelbusiness 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 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.
O Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Activity Code: S -23C - 01P ISSUED - REPAIR 11
Total Time:(H N:1,1 M )
0 1 Hours 0 0 Minutes
creaula cqurpment
i
NEMA 4X Box or Equivalent
❑ Yes
❑
No
Installer:
Box 12 inches Above Grade
❑
Yes
❑
NO
Certification #:
Box Adj. To Pump Tank
❑
Yes
❑
NO
Conduit Seated
❑
Yes
❑
No
'EHS:
Pump Manually Operable
❑
Yes
❑
No
'Activation.Method:
Date:
Approval Status
Alarm Audible
❑
Yes
❑
No
D Approved[] Disapproved
Alarm Visible
❑
Yes
❑
No
2244 - Daywalt, Andrew
'Operation Permit completed by,
Authorized State Agen
Date of Issue: 0 6/ 2 5/ 2 0 1 3
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 11 A. sewage septic system.
Rule .1961 requires that a Type TYPE 11 A. septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: N/A
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency ByCeitifiied Operator:
NIA
Reporting Frequency By Certified Operator: NIA
Rule .1961 requires that a Type IV and V septic systems designed for a homelbusiness owner must maintain a valid contract
with a public management entity with a certified operator or a private certified operator forthe life of the septic system.
Rule .1961 requires that Type VI septic systems designed fora homelbusiness 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 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.
O Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Activity Code: S -23C - 01P ISSUED - REPAIR 11
Total Time:(H N:1,1 M )
0 1 Hours 0 0 Minutes
OPERATION PERMIT
Davie County Health Department CDP File Number: 122016 - 1
210 Hospital Street Gb•130.60-012
P.O.Box 848
County File Number:
Mocksville NC 27028 Date:
Olnch
Drawing Drawing Type: Operation Permit Scale: OON/A k = ft.
•1X®d
Cyr
-I MCCU
Puy ' •
' o
Rse I
r
CONSTRUCTION For office Use Oniy
AUTHORIZATION *CDP File Number 122016-1
Davie
Count Health Department County ID Number:
Gb•130•SO-012
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 6/ 2 5/ 2 0 1 8
Applicant: Dwight Jackson Property Owner: Dwight Jackson
Address: 2255 NC Hwy 801 S Address: 2255 NC Hwy 801 S
Cay: Advance
State2ip: NC 27006
Phone 9: (336) 998-5357
/ Address/Road #: Subdivision:
2255 NC Hwy 801 S
Advance NC 27028
Structure: SINGLE FAMILY
V of Bedrooms: 2
# of People:
*Water Supply: PUBLIC
`Site Classification: PS
Saprolite System? QYes QNo
Design Flow:
Soil Application Rate:
'System Class ifx:ation/Do script ion:
*Proposed System:
Nitrification Field
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Aggregate Depth:
ft.
Cay: Advance
State/Zip: NC 27006
Phone 9* (336) 998-5357
ite Information
Phase: Lot:
Directions
Hwy 64 E right on 801 to Advance pass Ellis School 3rd
on right
System Specifications
Sq. ft.
Minimum Trench Depth:
Inches
Minimum Soil Cover.
Inches
Maximum Trench Depth:
Inches
Maximum Soil Cover:
Inches
*Distribution Type:
Septic Tank:
Gallons
1 -Piece: QYes
QNo
Pump Required: QYes QNo
0May Be Required
Pump Tank:
Gallons
1 -Piece: QYes
QNo
GPM—vs—
ft. TOH
8FeetO.C. g Inches O.C. Dosing Volume: _ Gallons
Feet
__8Inches
Feet Grease Trap: Gallons
inches Pre Treatment: ONSF OTS -1 OTS -II
Septic Tank Installer Grade Level Required: 01 011 0111 01V
Pagel of 3
• Gb-130-130.012
` CDP File Nurhber 122016 - 1 County ID Number:
❑ Open Pump System Sheet
air bystem Requireo:vTes vivo vivo, out nas AvauaDie Space
Trench Spacing:8Feet
Inches 0.
*Site Classification: Ps — O.C.
Trench Width: Q Inches
Design Flow: 2 4 0 — o Feet
Soil Application Rate: 0 - 3 Aggregate Depth: inches
*System Classification/Description: Minimum Trench Depth: 2 4 Inches
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover.
Inches
Maximum Trench Depth: Inches
'Proposed System: 25% REDUCTION
Maximum Soil Cover:
Nitrification Field Inches
Sq. ft.
No. Drain Lines *Distribution Type: GRAVITY -SERIAL
Total Trench Length: 1 0 0 ftPump Required: Oyes ONo OMay Be Required
Pre -Treatment: ONSF OTS -1 OTS -II
'Site Modifications
No grading or construction activity is 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 bevalld fora 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 beet 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: 2244 - Daywa. , Andiew A. Date of Issue:. 0 6 / 2 5 / 2 0 1 3
FV �rw
Authorized State Agent: Malfunction Log Oyes
go
OHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
S-10- CA'S issued - repair
Total Time:(HH:1.11.1)
0 1 Hours 0 0 1.1inutes
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
CDP File Number: 122016 -1
County File Number: Gb-130-130-012
Date: 06/25/2013
Q Inch
DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST
/ APPLICATION IP/ATC OSWW REPAIR
Name (,U I -Y c� (� Telephone Number
Address ;Z , ,�
Mailing Address (if different from above)
Email Address:
Subdivision Name Lot #
Directions b L L 0o),441v C<)/ --
al! 11 a / 9/Z( -Y/ o/v cam/ , (- 1- 350 AL)
Date System Installed Name System Installed Under
Type Facility Number Bedrooms Number People Served
Type Water Supply 0ou id V Specific Problem Occurring /i % :S'
Date Requested Cn -// - j3 Info Taken By (L
THIS IS TO CERTIFY THAT THE 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
)1Z
�DAVIE COUNTY HEALTH DEPARTMENT SEPTIC TANK PERMIT Date Z —
JHmer/Occupant To:
Address a? d4k Address ¢/4a c%S
Building Contractor pa 1�; 2f" Address Cal. � D'� Manufacturer's Name ��� �i.i� d1a01 Address �yc%
No. of lines T Width _4 n. Total length ft. No. sq. ft. e)D
Type of filter material Total tons used.
Plinimum REquirements: House Trailer Tank cap. 800 Sq. ft. line 400
Two-bedroom house 800 600
Three-bedroom house 900 900
No one shall install a septic tank in Davie County without a permit from the Health Offic
or his agent.
Date of Final Approval Signed:
Sanitarian
I hereby certify that the above septic tank has been installed according to speci-fication
Signed:
Septic Tafik Contractor
Note: Make sketch of disposal system on back of sheet and mail to Davie County Health
Center, Box 57, Mocksville, North Carolina 27028.
�. LcG�
e�
i
�c
�5<<�y�ASb itA
`tie safe
p ED 8V(13„pAC>E A. a 0390,
r Ma to: ay A. Purdy Route #2, Box 449, Advance, N. C. 27406
(teams) (slfMl and NYmbar) (GtYI (state) (Zip)
Mail future tax bills to:
(Name) (Street and NYmbM) (GtY) (luta) (21p)
STATE OF NORTH CAROLINA
COUNTY OF FORSYTH QUITCLAIM DEED
Know all Men by Then Presents, That BOBBY COPE and his wife—LYNN COPE
of Georgg gwn. Delaware (Heir of Beatrice Z. Purdy,
formerly M. Beatrice Z. Brown)
of*)wcytkJTmx2XJCtkin consideration of Ten and No/100---------------- Dollars
received of RAY L. PURDY (Widower)
have hereby released and forever quitclaimed, unto RAY L. PURDY (Widower) _
and his heirs and assigns forever, all such right, title and interest, as We haft in or to all that parcel of land lying in
Shady Grove Davie North Carol inn—, described., follows:
(TownsMP) ours r (State)
BEGINNING at a point in the center of N. C. Highway #801, Helen E. Z.
Roche Southwest corner and running thence in an Eastern direction with
said Roche Southern line South 850 East 439 feet to an iron stake,
Roche Southeast corner in W. J. Ellis line; thence South 10' 301 West
100 feet to an iron stake; thence North 840 West 440 feet to a point
in the center of Highway No. 801; thence North 10" 301 East 100 feet
with the center of the said Highway to the POINT AND PLACE OF BEGINNING,
and BEING Lot No. Five (5) of the property of W. J. Ellis and wife,
Hazel L. Ellis according to a survey and plat thereof prepared by S. L.
Talbert, RS. The above parcel of land is a portion of those lands
described by deed recorded in Book 53, page 296, Davie County Registry.
The purpose of this quitclaim deed is to release any and all interest
which the said Bobby Cope has in the above described property by virtue •
of the Last Will and Testament of MARY BEATRICE ZIMMERMAN PURDY (File
#93 E 131).
The above described property was deeded to the Deceased in Deed Book
81, page 108, in the Office of the Register of Deeds of Davie County,
in the name of M. BEATRICE Z. BROWN.
NO TAXABLE CONSIDERATION
DRAFTED BY T. DAN WOMBLE
PROPERTYADDRESS Route #2, BOX 449, Advance, N. C. 27006 VkXX P araA.] r_R _
TO HAVE AND TO HOLD the abovareleased premises unto the said RAY L. PURDY (Widower)
his heirs and assigns, to h i A and their only proper use and behoof
forever; so that neither of us nor any person, in our name and behalf, shall or will hereafter claim or demand any right
or title to the premises, or any part thereof; but they and each of them shall, by these presents, be excluded and forever barred.
t QED BOOK PAGEY.: O
OG199
•AVIS COUNTY 10-13-97 OZoL. ��53 P.M.
ii:.Y_M7E 197...L
ato ticaaoso w a,,,. ...�...o
STATE of $200.00. towr I OHM amstra tr am
O OR
SOUNA Real Estate
SPR Excise Tax Deputy
Excise Tax ab (I , Recording Time. Book and Page •
TaxLot No........................................................................................... Parcel Identifier No..................................... ...........................
Verifiedby........................................................................ County on the.............:... day of ...............:......................................... 19............
by
Mail after recording to ................ Mr.....&..?IuA... JQhn...DV.1&ht...JackaoA;.2255..Hwy..$01...Sauth....Advanc.e....NC..27006.
...........................................................................:........................................................................................:..............................................................
This Instrument was prepared by ....T ..Dan Womble, AttorneY.2
............................................. mN270.1..
......
Brief description for the Index Part of Lot 4 and all of Lot.L W. is Property Unrecorded
NORTH CAROLINA GENERAL WARRANTY DEED
THIS DEED made this ......8.01 day of............Qr,.tob.yX.................................. 19.37......, by and between
GRANTOR
RAYMOND L. PURDY
GRANTEE
JOHN DWIGHT JACKSON AND WIFE,
FRANCES H. JACKSON
•
Enter In appropriate block for each party- name, address, and, If appropriate, Character of entity, e.q. corporation or partnership.
The designation Grantor and Grantee as used herein shallinclude said parties, their heirs, successors, and assigns, and
shall Include singular, plural, masculine, feminine or neuter as required by context.
WITNESSETH, that the Grantor, for a valuable consideration paid by the Grantee, the receipt of which is hereby
acknowledged, has and by these presents does grant, bargain, sell and convey unto the Grantee in fee simple, all that
certain lot or parcel of land situated in the City of.......AdYanc—e..,,.,_............................. I.:.SAA4y,,,Grove................... Township,
Forsyth County, North Carolina and more particularly described as follows:
BEGINNING at an iron,. said iron being located in the Northwest
corner of Charles A. Spann, Deed Book 196, Page 285, Davie County
Registry and also being in the Eastern right of way line of U.S.
Highway 801; thence from said point of Beginning along the Eastern
right of way line of U.S. Highway 801 North it degrees 181 45" East
100.24 feet to a point; thence continuing along the Eastern right .
of way line of U.S. Highway 801 North 11 degrees 031 15" 49.99 feet
to an iron; thence South 84 degrees 591 15" East 411.48 feet to an
iron; thence South 10 degrees 181 05" West 49.76 feet to an iron;
thence South., 10 degrees 301 00" West 99.53 feet to an iron in
Spannls Northeast corner; thence along Spannls North line North 85
degrees 041.40" West 413.82 feet to an iron, the point and place of •
Beginning, containing 1.41 acres, more or less, .and being in
accordance with a survey prepared by Richard Parks Bennett, R.L.S.,
dated October 9, 1997.. The above described property being
informally known as Tax Lots 11 and 12, Block B, Map G-8-13, Davie
County Tax Maps. For back title see Deed Book 134, Page 373, and
Deed Book 175, Page 398.
N. C. Wr Aawrc. Funn No. 7 C� 1976. RrrUed 1977-,..wwnti.,.a ew, i.e.. m. �1f, r.w;M;M, N. a saes
MMC! W •,e,,,w,. M,.,leIre-
IIIIIIII
Davie County, NC - GoMaps Advanced Page I of I
2266 0
203
40m
100 ft 2271
http://maps2.roktech.net/davie_gomaps/index.htnl
Latitude; 35r, 55' 57.94' Longitude: -800 24' 31.78'
6/21/2013
• DAVIE COUNTY HEALTH DEPARTMENT SEPTIC TANK PERMIT Date a — '
,Z/Occupant , To"4
-7
f 'Address a7 t/4k
Address
Building Con. ractor 2-- Address
Cal. _ LManufacturer's Name �.�a �.(� �, Address
No. of lines / Width _46. Total length ft. No. sq. ft. DD
Type of filter material Total tons used
PIinimum REquirements: House Trailer Tank cap. 800 Sq. ft. line 400
Two-bedroom house 800 600
Three-bedroom house 900 900
No one shall install a septic tank in Davie County without a permit from the Health Offic
or his agent.
Date of Final Approval Signed:
Sanitarian
I hereby certify that the above septic tank has been installed according to specification
Signed:
Septic Tafik Contractor
Note: Make sketch of disposal system on back of sheet and mail to Davie County Health
Center, Box 57, Mocksville, North Carolina 27028.
�jl
1
�.,
(ass
V(K1fie Maf�{ta