661 Liberty Church RdOPERATION PERMIT
Davie- C quIn'ty Health Department
210 Hospital Street
P.O. Box 846
lvlocksvllle NC, 27028 "
Phone: 336-753-678D Fax: 336-753-1680
Applicant: William D. Grooms
Address: 661 Liberty Church Rd
CRY: Mocksville
state0l): NC 27028
Phone 9: (336)492-7502
Address/Road 9: Subdivision:
661 Liberty Church Rd
Mocksville NC 27028
Structure: SINGLE FAMILY
#of Bedrooms: 3
# of People:
'Water Supply: WA
*IP Issued by. 21`40 -Nat ns, Robert
'*CA issued by: 2140 - Natibm, Robed
Design Flow: 3 6 0
Soil Application Rate: 0 • 2 7 5
Nkrification Field
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Aggregate Depth:
(-'Property Owner William D. Grooms
Address: 661 Liberty Church Rd
CRY: Mocksville
StatefLip: NC 27028
hone #: (336) 492-7502
Phase:
Directions
Hwy 601 N. Left Liberty Church Rd
Lot:
"System .Classircation/t)esedption:
OR LESS)
Seprolfte System? OYes No
"Distribution Type: GRAVITY- PARALLEL (eq. d -box) Pump Required?
OYes Q)No
*Pre Treatment.
T
1 3 0 0 Sq. ft,
3
3 4 ft.
(finches O.C.
Feet O.C.
(Inches
(VFeet
inches
Minimum Trench Depth: 3
6
Inches
Minimum SoU Cover. 2-
4
Inches
Maximum Trench Depth:3
6
Inches
Maximum Soil Cover. 2
4
Inches
*System Type: INFILTRATOR QUICK 4 STANDARD
Installer: Randy Miller
Certification
*EHS: 2140 -Nations, Robert
Date: 0 5 / 1 3% 2 0 1 5
CDP Fite Number 192512-1 County ID Number:
■
Manufacturer.
STB:
Gallons:
Dosing Volume:
Date:
Gal Certification #:
Draw Down:
'Filter Brand:
*EH S:
*Chain:
ST Marker
11 Yes
El
No
nforced Tank:
11 Yes
11
No
1 Piece Tank:
El Yes
13
No
Let.
Long:
Installer.
Certification #:
*EH S:
Date:
Pump Tank
Manufacturer Installer:
PT: Certification 4:
Gallons: *EH S:
Date: C Date:
RiserSeeled ❑ Yes ❑ No
RiserHeight: El Yes 0 No (Min. 6 in.) W
nforced Tank: El Yes El No
EIAD- e
Al
I Piece Tank: El Yes 0 No M!,
Supply Line
Pie Size: Inch diameter Installer
Poe Length: feet Certification
*Schedule:
*EH S:
Pressure Rated 0 Yes 1:1 No Date:
. ...... ..
�pprovecl Wings El Yes 13 No
Pump Type:
Installer.
Dosing Volume:
Gal Certification #:
Draw Down:
Inches
*EH S:
*Chain:
Date:
Valves Accessible
El Yes
0
No
Flow Adjustment Valve
El Yes
El
No
Check -valve
El Yes
El
N o
"Ut
PVC Unions,
Ye s
El
No
h"N -0
O no
''R
Vent H016❑
Yes
0
No
- A,
Y'JR04, 0
Anti -siphon Hole
El Yes
El
No
CDP File Number 192512-1 County 1D Number:
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
"EHS:
Pump ManuallyOperable
❑
Yes
❑
No
*Activation Method:
Date:
�f
� ��
141a�rm Audia�'
❑Yes
F-1No
�� F ❑����i�%�-i/� "" F�D�SQ���ii%�d ��I�
Alarm Visible
❑Yes
F1
No
L ,¢ Ej
2140 - Nations. Robert
*Operation Permit completed by,
Authorized State Age ,..
.�.-
�"
Date of Issue: 0 5 I 1 3 a 0 1 5
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.,,ond allcondition's of the .improvement Permit and
Construction A,uthorization..This property is served by a TYPE tl,q. sewage septic system.
:
Rule :196TYPE1I A.
1 requires that a Type septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: N/A
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency ByCertified Operator,
WA
Reporting Frequency By Certified Operator. NIA
Rule .1961.. requires that a Type 1V and V septic,systems designed fora homelbusiness owner must maintain a valid contract
With a public.managemeet erttitywtkh a certified operatoror a p ate certified operator forthe life of the septic system.
Rule .1961 requires that Type VI septic systems designed for a hom elbusiness owner must maintain a valid contract with a
public management entity with a certified operator for the life of the septic system.
1
0y a, p
ame♦ i ne coniracr;
itinued proper performanc
systems execute such a'
4 Hand Drawing 01mportDrawing
**Site Plan/Drawing attached.**
__ __ _ _ _ _ _ _
_ ____ _ _ _ __ __ __ .
CaPERATlC1N PERM[T ,����,��� ,� .
Qavie Count�l�eaith D�partm�r�t CdP File Number:
21(1 Hospitat Str�et
P,O.Box848 COUt�ty FII� NUt'�b�E':
nnoc�svii�� �sc z�o2s �►ate: ! !
,�.�...., � . � � . .
Q1nch
Drar�in �raw�ng Type: O�eratior� Permit Scale: . . . . ��s�c�c . . .ft.
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_i
CONSTRUCTION
Minimum Trench Depth: 2 4 Inches
For office Use Only
Provisionally Suitable
AUTHORIZATION
Saprolite System?
*CDP File Number 192512-1
''
Davie Count Health Department
Y P
3 6 0
County ID Number:210
ut...
Hospital. Street
Maximum Soil Cover: 2 4 Inches
Evaluated For: REPAIR
*Distribution Type: GRAVITY - PARALLEL (eq. d -box)
P.O. Box 848
Township:
Gallons
Mocksville NC 27028
PERMIT VALID UNTIL:
Phone: 336-753-6780 Fax: 336-753-1680
Pump Required: QYes ONo OMay Be Required'
0 3/ 3 1% a 0 2 0
Applicant:
William D. Grooms
Property Owner: William D. Grooms
Address:
661 Liberty Church Rd
Address:
661 Liberty Church Rd
City:
Mocksville
City:
Mocksville
StatefZip:
NC 27028
State0p:
NC 27028
Phone #:
(336) 492-.7502
Phone #:
(336) 492-7502
/Address/Road M
661 Liberty Church Rd
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
*Water Supply: NIA
Subdivision: Phase: Lot:
Directions
Hwy 601 N. Left Liberty Church Rd
Donn 9 ^f'z
Minimum Trench Depth: 2 4 Inches
Site Classification:
Provisionally Suitable
Saprolite System?
OYes (J)NoInches
Minimum Soil Cover. 1 a
Design Flow:
3 6 0
Maximum Trench Depth: 3 6 Inches
Soil Application Rate:
0 - 2 7 5
Maximum Soil Cover: 2 4 Inches
*System Classification/Description:
*Distribution Type: GRAVITY - PARALLEL (eq. d -box)
TYPE 11 A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
Gallons
"Proposed System: 25% REDUCTION
1 -Piece: O Yes O N o
Pump Required: QYes ONo OMay Be Required'
Nitrification Field
1 3 0
9 Sq. ft. Pump Tank: Gallons
No. Drain lines
3
1 -Piece: Oyes ONo
Total Trench Length:
3 a 7 ft
GPM—vs— ft. TDH
Trench Spacing:
— g .
Inches O.C.
8Feet O.C. Dosing Volume: _ , Gallons
Trench Width:
3
Inches
@Feet
—
Grease Trap: Gallons
Aggregate Depth:
inches
Pre Treatment: ONSF OTS -I OTS -II
1 _
Septic Tank InstallerGrade:Level Required: 01 011 0111 OIV
Donn 9 ^f'z
CDP Fite Number 192512 -1
ir
*Site Classification:
Design Flow:
Soil Application Rate:
*System Classification/Description:
*Proposed System:
CWAI
N itrification Field
Sq. ft.
No. Drain Lines
Total Trench Length;
ft.
.County ID Number.
ONO ONO, but has Available S
i
❑ Open Pump System Sheet
Trench Spacing:
Q Inches 0.1
_ ()Feet O.C.
Trench Width:
Q Inches
_ 0 Feet
Aggregate Depth:
inches
Minimum Trench Depth:
Inches
Minimum Soil Cover.
W
Inches
Maximum Trench Depth:
Inches
Maximum Soil Cover:
Inches
*Distribution Type:
Pump Required: Oyes ONo OMay Be Required
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 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 forwastenwater System Constraction shall bevalid for a person equal to the period of validity of the Improvement Permlt, not
to exceed five years, and maybe issued attire sametime the improvement Permit issued (NCGS 130A -=(b)} If the installation has not been
completed during the period of validity of the Construction Permit, the Information submitted in theapplication for a permit" Construction.
Authorization is found to have been incorrect, falsified or changed, or the site Is altered, the permit or Construction Authorization shall became
Invalid, and may be suspended or revoked (.1937(8)). The person owning or controlling the system shall be responsible forassuring compliance
with the laws, rulers, and permit o nd goons regarding system location, installation, operatior% maintenance, monitoring, reporting and repair
ApplicanVLegal Reps. Signature Required? OYes ONO
Applicant/Legal Reps. Signature: Date:
*Issued By: 2140- Nations, Robert Date of Issue:. 0 3 3 1/ a 0 1 5
Authorized State Agent`./�--� Malfunction Log OYes } �.
€Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848 County File Number:
Mocksville NC 27028 Date: 0 3/ 3 1/ 2 0 1 5
Q Inch
Scale: , 0,13lock
()NIA
CDP File Number 192512-1
Drawing Drawing Type:, Construction Authorization
U
+ DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE QUEST Pro b law .
APPLICATION IP/ATC OSWW REPAIR
Name k1 J lM QfnS Telephone Number 55& y z'
Address 41
Mailing Address (if different froln above) (A-1 I
Email Address:
Subdivision Name Lot #
Directions
Date System Installed
Type Facility
Type Water Supply _
Name System Installed Under Ule I o
Number Bedrooms_ Number People Served
Specific Problem Occurring
7
Date Requested Info Taken By
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 .% l