Loading...
7704 Hwy 801SOPERATION PERMIT Davie County Health Department r 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Bruce Harry Address: PO Box 357 CRY: Cooleemee State2ip: NC Phone #: (336) 284-6180 27014 'CDP File Number 138202-1 M5 -160 -DO -4 County ID Number: Evaluated For: HDR/WWC �ownship: ("Property Owner: Cooleemee Church of God Address: 7704 NC Hwy 801 South City: Cooleemee State2ip: NC 27014 one #: —' Pmperty Location & Site Information Address/Road #: ubdivision: Phase: Lot: 7704 NC Hwy 801 South Cooleemee 4 Directions Struc URCH Hwy 601 South, right on Hwy 801. Church on Right across from grave yard. # of Bedrooms: # of People: 'Water Supply: PUBLIC 'IP Issued by. 'CA issued by: 2140 -Nations, Robert Design Flow: 1 0 0 Soil Application Rate: 0 - a 'System Classification/Description: TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) SaproliteSystem? OYes QNo 'Distribution Type: GRAVITY - PARALLEL (eq. d -box) Pump Required? OYes QNo 'Pre Treatment: J Drain field N ilrification Field 5 0 0 Sq. ft. No. Drain Lines 3 Total Trench Length: 1 6 7 ft. Trench Spacing:— 9 Inches O.C. Feet O.C. Trench Width:Inches 3 — Feet Aggregate Depth: inches Minimum Trench Depth: a 4 Inches Minimum Soil Cover. 1 a Inches Maximum Trench Depth: a 4 Inches Maximum Soil Cover: 1 a Inches 'System Type: INFILTRATOR QUICK 4 STANDARD Installer Randy Miller Certification #: 'EH S: 2140 - Nations, Robert Date: 0 8/.2 7 / x 0 1 4 Approval Status D Approved O Disapproved CDP File Number 13,8202 -1 Manufacturer. Sh(oaf STB: 760 Gallons: 1000 Date: 05/ 0 4/ 2 0 1 4 "Filter Brand: ❑ No RiserHeight: ❑ Yes ST Marker: ❑ Yes E No nforced Tank: ❑ Yes 0 NO 1 Piece Tank: ❑ Yes 0 No Manufacturer. PT: Gallons: Countv ID Number: M5 -160 -Do -4 Let. Long: Installer: randy miller Certification #: `EH S: 2140 - Nations, Robert Date: 0 8/ 2 7/ 2 0 1 4 Approval Status O Approved ❑' Disapproved Pump Tank Date: / / RiserSealed ❑ Yes ❑ No RiserHeight: ❑ Yes ❑ No (Min .6 in.) nforced Tank: ❑ Yes ❑ No 1 Piece Tank: ❑ Yes ❑ No Pipe Size: inch diameter Pipe Length: feet 'Schedule: Pressure Rated ❑ Yes ❑ NO ipp roved fittings ❑ Yes ❑ No Installer: Certification #: 'EHS: Date: Approval Status ❑ Approved ❑ Disapproved pply Line Installer. Certification #: "EHS: Date: / / Approval Status Approved ❑ Disapproved (Dosing PumpType: — Installer: Volume: Gal Certification #: 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 0 Yes ❑ NO CDP File Number 138202 -1 County ID Number: M5 -160 -DO --4 Electric Eauloment NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer: Box 12 inches Above Grade ❑ Yes ❑ NO Certification #: Box Adj.To Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No *EH S: Pump Manually Operable ❑ Yes ❑ No *Activation Method: Date: Alarm Audible E3 Yes ElNo Approval Status ❑ Approved ❑ Disapproved Alarm Visible ❑ Yes ❑ No 2140 - Nations, Robert *Operation Permit completed by: Authorized State Agent: Date of Issue: $ / a a 0 1 4 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 By Certified Operator: N/A Reporting Frequency By Certified Operator: N/A 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 fora home/business 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 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. 01 -land Drawing Olmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC Drawing Drawing Type: Operation Permit CDP File Number. 138202-1 County File Number: MS -160 -DO --4 27028 Date: O Inch Scale: OlBlock ON/A o �Oo�15F--I i5 to Ilk— LJ--- II IIl II Nall\ � II_i I I i I 1 II I� I I I I, I I Imo'. i U HEALTH DEPARTMENT RELEASE Davie County Health Department y 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Bruce Harry Address: PO Box 357 City: Cooleemee State2ip: NC 27014 Phone #: (336) 284-6180 For Office Use Only *CDP File Number 138202-1 M5 -160 -DO -4 County ID Number. valuated For. HDR/WWC PERMIT VALID 0 5/ 1 3/ 2 0 1 9 UNTIL Property Owner. Cooleemee Church of God Address: 7704 NC Hwy 801 South City: Cooleemee State0p: NC 27014 Phone #: I-,— Property Location & Site Information Address 7704 NC Hwy 801 South Subdivision: Phase: Lot: Road # Cooleemee NC 27014 CHURCH Township: 'Structure: Directions # of Bedrooms: # of People: Hwy 601 South, right on Hwy 801. Church on Right across from grave yard. 'Water Supply: PUBLIC Basement: F] Yes n No "Proposed Improvement: Fellowship Hall Type of Business: Total sq. Footage: No. Of Employees: This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps. Signature Required? OYes ONO Applicant/Legal Reps. Signature; *Issued By 2140 -Nations, Robert Authorized State Agent: __j *Date: *Date of Issue: 0 5/ 1 3/ 2 0 1 4 No **Site Plan/Drawing attached.** ®Hand Drawing Olmport Drawing Drawing Type: HEALTH DEPARTMENT RELEASE Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Health Department Release CDP File Number: 138202 -1 County File Number: M5 -160 -Do -4 Date: 0 5/ 1 3/ 2 0 1 4 Q Inch Scale: . QBlock = ,ft. Q N/A I d l i i rayc 4Q v1 c 17 ii I ; ! _-__. -------- ------ _ I___1 __l_ rayc 4Q v1 c w APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC Davie County Environmental Health RUC EIVP P.O. Box 848/210 Hospital Street Mocksville, NC 27028 oat�t b (336)753-6780/ Fax (336)753-1680 Application For:., ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct (ATC) ❑ Both Type ofApplication: ❑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. APPLICANT INFORMATION Name rUc.c- 4yrs Contact Person _6ry�e.- 40-0- i Address_Po P-vvL 3C_-.)-1 Home Phone 336_SL%H- (al gb City/State/ZIP Q_yo1 e eme.e. ' I4c. X76 ► 4 Business Phone Email RASA -or bry c e V-,rArM 0) ' rA-rnc. , n' -l - Name on Permit/ATC if Different than Above Mailing Address City/State/Zip Specify Problem Occurring: " gud ._. 4b c - J— e KI 6&J Wt Add Au -,a eu; SIS Aln IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms # Bathrooms Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes ❑No Basement Plumbing: ❑Yes []No IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business C\yrvl,. Total Square Footage of Building _+ Lt?l (Db # People # Sinks q # Commodes # Showers # Urinals / Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: R(!onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: R<ounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes &KNo 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 and les. I understand t t I am responsible for the proper identification and labeling of property lines and corners and locati agging o t mg tli.lieme/facility location, proposed well location and the location of any other amenities. Prop owner's or owner' gal representative signature Site Revisit Charge Date(s): -Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account # `�2, Revised 11/06 Invoice # 1 IRS - x IShelter Shelter (Gravel Floor) (Concrete Floor) i Masonry 88Q Pit v stied I x Chain Link Fence ---- x -- -- _ v 1 �x Chain Lir r-- - - - - - - - - - - - - - - - - 1 1 1 1 I 1 1 1 I I Gravel/Grass Parking Lot 1 I Pro jrZ.r� l,ip 40 X (pc Asphalt Parking Lot Asphalt Drive YI V-UndergroundFuel i �I m Tank Spouts Stockade Fence - Stoop do Handicap Romp Concrete i — WOik Parking 7 , I Area Steps 1 1 Covered Porch 1 1 , r _ Brick Church rr O ;;1 PP -O ,PI o Q ,CI of I IMr 7 1 1 1 1 r 1 Stoop / L-3 7„7 1" OP FndwM Brick Sign O k` / /Fnd 1&1/2" EIP N ° Concrete r walk -`I r Bent/Fnd L -1---7-- -M� -� TP El PP CC)