6999 Hwy 801S OPERATION PERMIT
or tice u1se univ
P; Davie County Health Department *CDA File Number 123660-11
210 Hospital Street Ls-000-00-044
P.O.Box 848 County ID Number.
Mocksville NC 27028 Evaluated For. NEW
Phone:336-753-6780 Fax:336.753-1680 Township:
Applicant: Perry Miller r
operty Owner. Perry Miller
Address: 6995 NC Hwy 801 S ddress: 6995 NC Hwy 801 S
City: Mocksville ity: Mocksville
State2ip: NC 27028 StatefZip: NC 27028
Phone#: (336)284-4228 Phone#: (336)284-4228
Property Location & Site Information
Address/Road #: "K Subdivision: Phase: Lot:
NC Hwy 801 S � ' Y
Mocksville NC 27028 Directions
Hwy.601 South to Hwy 801, turn left on 801 going
Structure SINGLE FAMILY north one mile on right
#of Bedrooms: 3
#of People:
*Water Supply: PUBLIC
*IP Issued by, *System Classification/Description:
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by:
- Saprolite System? OYes QNo
Design Flow: 3 6 0 * GRAVITY-SERIAL Pump Required?
Distribution Type: QYes (7No
Soil Application Rate: 0 3 *Pre Treatment:
Drain field
Nitrification Field. 1 _ a _ 0 0 SQ *System Type: INFILTRATOR QUICK 4 STANDARD
No. Drain Lines a Installer: Joe Stallard
Total Trench Length: 3 0 0 ft• Certification#: 3101
Trench Spacing: _ 9 ()Inches O.C.
(0)Feet O.C. 'ENS: 2140-Nations,Robert
Trench Width: _ 3 Olnches
Date: 1 a / 0 4 / a 0 1 3
Aggregate Depth: inches
Minimum Trench Depth: a 4
Inches
Minimum Soil Cover. 1 a Approval Status;
Inches -
MaximumTrench Depth: 3 6 [E Approvetl Disapprovetl .
Inches
_ Maximum Soil Cover
Inches
CDP File Number 123660 - 1 Septic Tank County ID Number: 1.5.000.00.044, .
Manufacturer. S(hoaf Lat.
STB: 760 Long: ,
Gallons: 1000
Installer. Joe Stafford
Certification#: 3101
Date: 8 8 / 0 9 / x 0 1 3
EHS: 2140-Nations,Robert
*Filter Brand: POLYLOK PLA 22 With Pipe Adapter
ST Marker: ❑ Yes n No Date: 1 a / 0 4 / 0 a 1 3
Reinforced Tank: E] Yes ® No
Appiroval Status
Piece Tank: ❑ Yes Cl No '17ApproveNit
d❑ Disapproved
Pump Tank
Manufacturer Installer.
PT: Certification#:
Gallons: *EHS:
Date: / / Date:
RiserSealed ❑ Yes ❑ No
RiserHeght:_❑ Yes ❑ No (Min.6 in.) A rovalStatus
PP { ,
Reinforced Tank: ❑ Yes ❑ No ❑ Approved❑bDlsappmved
Piece Tank: ❑ .Yes El No
Supply Line
Pipe Size: inch diameter Installer.
Pipe Length: feet Certification#:
*Schedule: *EHS:
Pressure Rated ❑ Yes ❑ No Date: /
Approved fittings ❑ Yes ❑ NO App �ovaifatus
❑ Approved❑ Dlsapprovetl
Pump e
Pump Type: Instager.
Dosing Volume: — Gal Certification#:
Draw Down: Inches *EHS:
*Chain:
Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ NO
Check-valve ❑ Yes ❑ No -AjpIWial Status', ,
PVC unions ❑ Yes ❑ No ❑:Approved❑ Disapproved
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole ❑ Yes ❑ No
coP File Number 123660 - 1 County ID Number: 1s-000-00.044
Electric Equipment
C
EMTinches
or Equivalent ❑ Yes ❑ No Installer.ox 1Above Grade ❑ Yes ❑ No
Certification#:
Bo Pump Tank ❑ Yes ❑ No
Conduit Sealed ❑ Yes ❑ No *EHS:
Pump Manually Operable ❑ Yes ❑ No
*Activation Method: 01
Date:
Approval Status 3s
Alarm Audible 13 Yes C3No p Approved 0, Disapproved
Alarm Visible ❑ ��7es ❑�Wo
214 -Nation.Robert
*Operation Permit completed by:
Authorized State Agen Date of Issue: 1 a / 0 4 / a 0 1 3
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 a A. sewage septic system.
Rule .1961 requires that a Type.-TYPE 11 A. septic system meet the following criteria:
Minimum System Review By The Local Health Department: N/A
Management Entity: OWNER
Minimum System InspectionlMaintenance Frequency ByCertified 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 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 ownerand 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.
OHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT 123I - ')
Davie County Health Department CDP File Number:
210 Hospital Street l.5-000.00-044
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: !
Olnch
Drawing Drawing Type: Operation Permit Scale: ON A k ft.
(J
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J-1
3
CONSTRUCTION FEvaluated
or office Useonly
AUTHORIZATION I ��� mber 123660= 1
Davie County Health Department ` umber: Ls-oao-oao�a
210 Hospital Street �' r: NEW
P.O. Box 848
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 1 1 / 1 8 / 2 0 1 8
Applicant: Perry Miller Property Owner. Perry Miller
Address: 6995 NC Hwy 801 S Address: 6995 NC Hwy 801 S
City: Mocksville City: Mocksville
State/Zip: NC 27028 State/Zip: NC 27028
Phone#: (336)284-4228 Phone#: (336)2844228
Property Location & Site Information
r
ess/Roid #: Subdivision: Phase: Lot:
Hwy 801 S
cksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 601 South to Hwy 801, tum left on 801 going north
one mile on right
#of Bedrooms: 3
#of People:
"Water Supply: PUBLIC
System Specifications
(Site Classification: PS Minimum Trench Depth: 2 4 Minimum Soil Cover. Inches
rolite System? OYes @No Inches
gn Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches
Soil.Application Rate: 0 - 3 Maximum Soil Cover: Inches
*System Classification/Description: *Distribution Type: GRAVITY-SERIAL
TYPE II A CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic lank:
1 0 0 0 _ Gallons
*Proposed System: 1-Piece: QYes QNo
Pump Required: QYes @No OMay Be Required
Nitrification Field Sq ft Pump Tank: Gallons
No. Drain Lines 1-Piece: QYes ON
Total Trench Length: 3 0 0 tt. GPM—vs-- ft. TDH
Trench Spacing: Inches O.C.
OFeet O.C. Dosing Volume: _ Gallons
Trench Width: Inches
8Feet Grease Trap: Gallons
Aggregate Depth: inches
Pre-Treatment: ONSF OTS-1 OTS-Il
Septic Tank Installer Grade Level Required: 01 Oil 0111 OIV
'CDP File Number 123660 - 1 County ID Number: L5-000-00-044
❑ Open Pump System Sheet
Repair System Required:QYes ONo ONo, but has Available Space
rDesign
System Trench Spacing: inches 0.
ification: PS — O Feet O.C.
Trench Width: Q Inches
w: 3 6 0 — 0 Feet
Soil Application Rate: 0 - 3 Aggregate Depth: inches
._.__.
*System Classification/Description: Minimum Trench Depth: '2 4 Inches
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. Inches
Maximum Trench Depth:
"Proposed System: 25%REOUCTION 3 . 6 , Inches
Maximum Soil Cover:
Nitrification Field Inches
Sq. ft.
No. Drain Lines
*Distribution Type: GRAVITY-SERIAL
Total Trench Length: 3 0 0Pump Required: OYes .@No ()May Be Required
ft.
Pre-Treatment: ONSF OTS-1 OTS-11
"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 ofthis 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 bevalid fora person equal to the period of validity of the improvement Permit,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 Permlt,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 maybe suspended or revoked(.1937(g)).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)).
ApplicanULegal Reps.Signature Required? Oyes @No
Applicant/Legal Reps. Signature: Date:
*Issued By: 2244-Daywalt.Andrew Date of issue: . 1 1 / 1 8 / 2 0 1 3
Authorized State Agent: Malfunction Log OYes
@Hand Drawing Olmport Drawing Total Time:(HH:6114)
**Site Plan/Drawing attached.**
- - 0 1 0 0 ..,_... -
• CONSTRUCTION AUTHORIZATION 123660 - 1
Davie County Health Department CDP File Number:
210 Hospital Street
P.O.Box 848
County File Number; 1-5-000-00-044
Mocksville NC 27028 Date: 1 1 / 1 8 / 2 0 1 3
Olnch
Scale: OBlock
Drawing rawing Type: Construction Authorization = ft.
QN/A
i
- APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC
UD Davie County Environmental Health
v P.O.Boz 848/210 Hospital Street -PAID
Mocksville,NC 27028s -
n (336)753-6780/F;A/
(3�37 o53
� ��°i3Application For: Site Evaluation/improvement Permit utzation To Construct(ATC) ❑ Bo
Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/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.
APPTJC:ANT ZWORMATION
Name krev /'T i<�� f Contact Person
Address ?6 ( Sd cA 71 Home Phone
City/State/ZIP o c- ,C'.Sy i I& IV-42. .9-70-:Z9 Business Phone 33 6 -,34,5--336L?
Email
Name on Permit/ATC if Doerent than Above Sa m a.
Mailing Address .Sc, in e City/State/Zip
PROPERTY INFORMATION *Date House/Facility Comers Flagged
/0 )// / / 3
NOTE_:, A survey,plat or site plan must accompany this application. Included: ❑ Site.Plan ❑Plat(to scale)
(Permit is v d for 60 months with site plan,no expiration with complete plat.)
Owner's Name' 'Ile r r r Phone Number
Owner's Address w ...City/State/Zip Al. C. a 7 d�
Property Address 5 Cit-— _ � ,o '
Lot.Size Tax PIN# '0 - .0 q(�
Subdivision Name(ifapplicable) Sectiona,ot#
Directions To Site: 6 0 1 -f p $0 1 (L) t M; e o n
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 ✓3f�9
Does the site contain jurisdictional wetlands? Yes ✓No
Are there any easements or right-of-ways on the site? Ji es N
Is thesitesubject to approval by another public agency? Yes r_ o
Will wastewater other than domestic sewage be generated? Yes ✓ko
TF RFS1DF,NC.F,FIT J,01 TT TRF BOX RRT,OW
m
ple #Bedrooms #Bathrooms Garden Tub/Whirlpool ❑Yes o
ent: ❑Yes o Basement Plumbing: ❑Yes B190
.IF ETON-RFSmF.NC E FILd:,OUT THE B0X.BFJ,0W
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: bl( onventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: 'County/City.Water ❑New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve?"L7 Yes RoF40
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 IAereby 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 corers and locating and flagging
or Aking the ho e/f ty.location,proposed well location and the location of any other amenities.
Prope wner's or owner's legal representative signature Site Revisit Charge
Date(s):
a y — 13 Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No � Account#
a3660
Revised 11/06 t � Invoice# /� (,h Zn
X7000 -
7010
(U( 09 12 gib w�
:T I
7005j0\44
,i
Bot X7037 O 7S'
704S-"-,
125
.µ/f �• .� \, x,7021
126
tT oP-
All data is provided as Is without warranty or guarantee of any kind either expressed or Implied including but not limited to the Implied
C�
tw iE warranties of merchantability or fitness for a particular use.All users of Davie County's GIS website shall hold harmless the County of G U N�
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. PCI n{ted.Sep 25, 2013
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: Tax PIN/EH#: L5 000-0o;_ogq
Billed To:?e.,r(q Mj Subdivision Info:
Reference Name: Location/Address: oFp NW 061-5
Proposed Facility, �r Property Size: Date Evaluated: ho i/3
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope% o C
HORIZON I DEPTH p- 0_ .yk
Texture group
Consistence
Structure .5
Mineralogy 4:
HORIZON II 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 �� ps
LONG-TERM ACCEPTANCE RATE .3
SITE CLASSIFICATION: �S EVALUATION BY: /` 040-ii) �1)A%W j
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS:
LEGEND
Landscape Position
R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope j
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 SIC-Silty clay C-Clay
CONSISTENCE
Moist
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
�rCt
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
LYQtes
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-Lon¢-term accentance rate- nal/dav/ft2 rurur%nvnc
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