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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 I � - II f I i f 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- 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