195 Leisure Ln;.r OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753.1680
Applicant: Kathleen Connors
Address: 195 Lesiure Lane
City: Mocksville
StatefZip: NC 27028
Phone #: (336) 463-5793
Property owner. Kathleen Connors
Address: 195 Lesiure Lane
CRY: Mocksville
State/Zip: NC 27028
Phone #: (336) 463-5793
Property Location & Site Information
Address/Road #: Subdivision:
P1 95 Lesiure Lane
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
*Water Supply: EXISTING WELL
*IP Issued by.
*CA issued by: 2140 -Nations, Robert
Design Flow: 3 6 0
Soil Application Rate: 0 - a 5
t
Nitrification Field
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Aggregate Depth:
Phase: Lot:
Directions
Hwy 601 N, left on Childrens Home Rd. then right
onto Lesiure Lane.
*System Classification/Description:
TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
SaproliteSystem? QYes QNo
*Distribution Type: NIA Pump Required?
QYes QNo
'Pre -Treatment:
Drain field
1 3 9 2 Sq. It.
3
3 4 4 ft•
9 Inches O.C.
Feet O.C.
()Inches
(4)
y gFeet
inches
Minimum Trench Depth: 3
6
Inches
Minimum Soil Cover. 2
4
Inches
Maximum Trench Depth: 3
6
Inches
Maximum Soil Cover: a
t
4
Inches
*System Type: INFILTRATOR OUICK 4 STANDARD
Installer: Sherman Dunn
Certification #: 2702
*EH S: 2140 -Nations. Robert
Date: 0 5/ 2 4 / 2 0 1 6
CDP File Number 124633 -1
Manufacturer.
STB:
Gallons:
Date:
*Filter Brand:
ST Marker. ❑ Yes ❑ No
Reinforced Tank: ❑ Yes ❑ No
1 Piece Tank: ❑ Yes ❑ No
Manufacturer.
PT:
Gallons:
County ID Number: B3.000-OM'.2
I.
Lat.
Long:
Installer:
Certification #:
*EH S:
Date: / /
Pump Tank
Date:
/
/
RiserSealed ❑
Yes
❑
No
RiserHeght: ❑
Yes
❑
No (Min.6 in.)
einforced Tank: ❑
Yes
❑
No
O Piece Tank: ❑
Yes
❑
No
Pipe Size: inch diameter
Pipe Length: feet
*Schedule:
Pressure Rated ❑ Yes ❑ No
Approved fittings [3 Yes ❑ No
Installer
Certification #:
*EHS:
Date:
uppiy Line
Installer:
Certification #:
*EH S:
Date:
Pump Type: Installer
Dosing Volume: — Gal Certification #:
Draw Down: Inches *EHS:
*Chau:
Date:
Valves Accessible
❑ Yes
❑
No
Flow Adjustment Valve
❑ Yes
❑
No
Check -valve
❑ Yes
❑
No
lApp,roval Status
PVC unions
E] Yes
❑
No
❑ Apprayetl ❑t. Dtsapprovetl
Vent Hole
Anti -siphon Hole
❑ Yes
0 Yes
❑
❑
No
No
CDP File N11mber X124633 -1 County ID Number: 83.000-MO12
Electric EaulDment
NEMA 4X Box or Equivalent
❑ Yes
❑
No
Installer:
Box 12 inches Above Grade
❑
Yes
❑
No
Certification #:
Box Adj. To Pump Tank
[:1Yes
❑
No
Conduit Seated
❑
Yes
❑
No
*EHS:
Pump Manually Operable
❑
Yes
❑
No
*Activation Method:
Date:
Approval Status
Alarm Audible
❑Yes
❑
No
❑Approved
❑ ' D sapproved .
Alarm Visible
❑
Yes
❑
No
2140 • Nations, Robert
*Operation Permit completed by:
Authorized State Agent: - Date of Issue: 0 5/ a 4 / 2 0 1 6
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 It 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: NIA
Management Entity: OWNER
Minimum System InspectioniMaintenance 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 for a 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 by a 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.
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Operation Permit
CDP File Number: 124633-1
County File Number: 83-000-oa012
Date: 1
Q Inch
Scale:. QBkock A.
ON/A
tom„
QTS 1
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1
CONSTRUCTION
AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680 0 5 / 1 3/ a 0 1 9
Applicant: Kathleen Connors Property Owner: Kathleen Connors
Address: 195 Lesiure Lane Address: 195 Lesiure Lane
City: Mocksville City: Mocksville
State/Zip: NC 27028 State/Zip: NC 27028
Phone #: (336) 463-5793 Phone #: (336) 463-5793
/"Address/Road M Subdivision:
195 Lesiure Lane
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
*Water Supply: EXISTING WELL
Phase: Lot:
Directions
Hwy 601 N, left on Childrens Home Rd. then right onto
Lesiure Lane.
Specification
Page 1 of 3
Minimum Trench Depth:
a 4
Inches
\Site
Classification:
Provisionally suitable
Minimum Soil Cover:
1 a
Saprolite System?
O Yes 9 No
Inches
Design Flow:
3 6 0
Maximum Trench Depth:
3 6
Inches
Soil Application Rate:
0 .2 5
Maximum Soil Cover:
a 4
Inches
*System Classification/Description:
*Distribution Type:
TYPE II A. CONY SYSTEM (SINGLE-FAMILY
OR 480 GPD OR LESS) Septic Tank:
Gallons
*Proposed System: 25016 REDUCTION
1 -Piece:
OYes
O No
Pump Required: OYes
®No
O May Be Required
Nitrification Field
1 4 4
0 Sq. ft. Pump Tank:
Gallons
No. Drain Lines
3
1 -Piece:
OYes
ONo
Total Trench Length:
3 6 0
GPM
--vs--
ft. TDH
ft
Trench Spacing:
— 9
Inches O.C.
Feet O.C. Dosing Volume:
_
Gallons
Trench Width:
3
Q Inches
Feet
—
Q9 Grease Trap:.Gallons
Aggregate Depth:
inches
Pre -Treatment: ONSF OTS -1 OTS -11
Septic Tank Installer Grade Level Required: 01
Oil 0111
01V /
Page 1 of 3
CDP File Number. 124633 - 1
Kepair bysten
*Site Classification:
Design Flow:
Soil Application Rate:
*System Classification/Description:
*Proposed System:
Nitrification Field
No. Drain Lines
Total Trench Length:
County ID Number: 63-000-00-012
❑ Open Pump System Sheet
ired:OYes O No O No, but has Available
Trench Spacing: O Inches O.
O Feet O.C.
Trench Width: — O Inches
o Feet
Aggregate Depth:
inches
Minimum Trench Depth: Inches
Minimum Soil Cover:
Inches
Maximum Trench Depth:
Inches
Maximum Soil Cover:
Inches
Sq. ft.
*Distribution Type:
ft. Pump Required: OYes O No O May Be Required
Pre -Treatment: O NSF OTS -1 OTS -II
*Site Modifications
ad
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. R -mv
750
*Permit Conditions
The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements. R;,,'
2000
This Authorization for Wastewater System Construction shall be valid for a 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 130A336(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, rules, and permit conditions regarding system location, Installation, operation, maintenance, monitoring, reporting and repair
(1938(b)).
Applicant/Legal Reps. Signature Required? Oyes O No
Applicant/Legal Reps. Signature: Date:
*Issued By: 2140 - Nations, Date of Issue: 0 5 / 1 4 /-a 0 1 4
Authorized State Agent: Malfunction Log OYes
Hand Drawing . O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
CDP File Number: 124633 - 1
County File Number: B3-000-00-012
Date: 05/14/a014
O Inch
Drawing Drawing Type: Construction Authorization Scale: , p Block
Cj �U
G
V
w
a �'
lot tjA
Page 3 of 3
P1 P2
-ft.
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
CDP File Number: 124633 - 1
County File Number: B3-000-00-012
Date: .0.5, / 14/ 2 0 14
Click below to import an image from an external location: Drawing Type: Construction Authorization
Page 3 of 3
P1 P2
'. :DEED IpOK1PAC'����� ��-� f'-•� �.i���s' PAGE-
Mai1To: Thomas W. Connors Sr. v .$nrrn 1300
—
WARRANTY DEED—Form WD402 Printed and for talc bg jt►mcs Williams & Co., Inc., Yadkinvill�N�C;
STATE OF NORTH CAROLINA, DAVIE County.
THIS DEED, Made this Ist day of September 19—L—, , by and between GL�FOSTER & wife. DORIS
M'Q$Pg; RyRT RFAVIS & wife. MILDRED REAVIS and KENNM.f LEE FOSTER & wife, GAIL FOSTER
of Yadkin County
and state of North Carolina, hereinafter called Grantor, and THOS W. CONNORS, Sr. and wife, KATHLEEN H. CONNORS '
of Davie County and State of North Carolina, hereinafter :
cOed•Grantcc.
WITNESSETH: That the Grantor, for and in consideration of the sum of —.SOD L_=DEED—A=x+101 04—""'— Dollars
and other good and valuable considerations to him in hand paid by the Grantee, the receipt whereof is hereby acknowled ed. has given, granted. bargained; sold
turd conveyed, and by these presents does give, grant, bargain, sell, convey and confirm unto the Grantee, his heirs andfor successors and assigns, premises in .
Clarksville Township, Davie County, North Carolina, described as follows:
BEGINNING • at a point in the line of Robert Riddle heirs, the Southeast corner
of the within described lot, said point being North 86 delta. 10 minutes West 1063
feet from Robert Riddle Heirs Northeast corner in the center of State Road No. �.
1329, and runs North 7 dega. 04 minutes East 208.9 feet to a point in the South
margin of a 60 foot street; thence with the South margin of said street North 83
degs. 37 minutes West 250 feet to a point, the NOrthwest corner of the within
described lot; thence South 7 de'gs. 04 minutes West* 215 feet to a point in Robert ..
Riddle Heirs line, the Southwest corner of the wtihin described lot; thence South
86 dega. 10 minutes East 250 feet to the point and place of BEGINNING, containing "
1.21 acres, more or less, and being Lots Nos. 10 and ll'of an unrecorded plat of
Cranfill Development.
r The right of ingress and egress over an existing 60 -foot wide street is hereby f'
granted herewith
Reference is made to Deed Book 939* page 218,.,:Davie County Registry.
DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST
APPLICATION IP/ATC OSWW REPAIR .
Name 7� r Telephone Number z43�7q ?J
Address r._ N ✓i 7�
Mailing Address (if different from above)
Email Address:
Subdivision Name
Directions
it #
-000 -00-0/2,
I. -Zoo A&
Date System Installed Name System Installed Under
Type Facility Number BedroomsNumber People Served
Type ater Supply Specific Problem Occurring
Okgp %6alN 3�
Date Requested AR— 3 Info Taken By
THIS IS TO CERTIFY THA 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
I ni/6�3
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'Note: Issued in Compliance with G.S. of North Cardlina Chapter 130—Article 13c.
. Permit Number
ry�ftName
Date
Location 12�i
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home Business Speculation
No. Bedrooms s No. Baths �z No. in Family `
Garbage Disposal YES ❑ NO ❑ Specifications for System: 90d
Auto Dish Washer YES ❑ NO 0
Auto Wash Machine YES C] NO C]�,�OX ,3'Ud Jr�XfG
Type Water Supply
'This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit by I
'Contac pl_esentative of the Davie County Health Department for final inspection of this system between 8:30-
M. or 1:017=h30,P.M. on day 6f completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by {rt lruiv
RouS �—
Certificate of Completion Date
h
"The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
l
r`
Improvements permit by I
'Contac pl_esentative of the Davie County Health Department for final inspection of this system between 8:30-
M. or 1:017=h30,P.M. on day 6f completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by {rt lruiv
RouS �—
Certificate of Completion Date
h
"The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND ' CERTIFICATE OF COMPLETION
*Note: _Issued in Compliance with G.S. of North Carolina Chapter 130 -Article 13c.
Permit Number
Name aOOy!-45 63 AA Q rs Date
Location 1,n, tj - _r . [-,,r4 f, 132-S
f -Ul� LA)!r4•i „ II
Subdivision Name
Lot No.
Sec. or Block No
Lot Size House Mobile Home —`~- Business Speculation
No. Bedrooms
3 No. Baths f No. in Family
Garbage Disposal YES [j NO p-- Specifications for System: 9pdsov7W,14
Auto Dish Washer YES ❑ NO E]
Auto Wash Machine YES ❑ NO ❑
Type Water Supply It A)-00 --- Sys
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
t'
Improvements permit by ` \' • %� ���-r�1
v
*Contact s cpQ esentative of the Davie County Health Department for final inspection of this system between 8:30-
A.M. or 1Z0=1-30_P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed byI-( ,r 51\LntL-NS
f
Certificate of Completion�'� Date
*The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
R.
r-^
DAVIE COUPPTY HEALTH DEPART TENT
ENVIP,OITi.i'ENTAL HEALTH SECTION
SOIL/SITE EVALUATIOI?
ITAI��t-{aw�1�S Vii . C-oNd�syR 9 _ '�R-. DATE
ADDRESS —% �A�7au�S 7,QAa:N /dos%
LOCATIOid Cao/ti - Le,4,4
Y/iD.L':Nu',Ile- , N��'• 27v6ZS /32�/� ��-"` o:,e� / 1)
LOT SIZE
TOPOGRAPHY:
Vo
SOIL TE',,TUBE: _exAfJ p c1 C GA -Y
<,
SOIL STRUCTURE:
DEPTH:
RESTRICTIVE HORIZONS:
PERCOLATION PATE:
L 2 p � 2.
s.
Presoak
IIark & time
Drop
Time
Pate/Hin. Inch
1S`
20
AAJ
***CLASSIFICATIOII:
Suitable Provisionally Suitable Unsuitable
COI'jl-:,IEIITS:
W Ichi WE.LC..-
SAFITARIAP
SITE DIAGrAM -TT
h � ►� �J►Zn �3
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