143 Livengood RdOPERATION PERMIT
Davie County Health Department
° ¢ 210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Ronald Jones
Address: 142 Cedar Hill Lane
City: Advance
State/Zip: NC 27006
Phone #:
Property Loca
Address/Road #: Subdivision:
143 Livengood Road
Advance NC 27006
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
*Water Supply: N/A
*IP Issued by:
*CA Issued by: 2140 - Nations, Robert
Design Flow: 3 6 0
Soil Application Rate: 0 a 7 5
Nitrification Field
No. Drain Lines
Total Trench Length
Trench Spacing:
Trench Width:
Aggregate Depth:
*CDP File Number 237709 - 1
5778374515
County ID Number:
Evaluated For: REPAIR
�ownship:
/Property Owner: Ronald Jones
Address: 142 Cedar Hill Lane
City: Advance
State/Zip: NC
Phone #:
ion & Site Information
Phase: Lot:
Hwy 64 East, left on Fork Bixby Rd. right on
Livengood Rd. Home on left
*System Classification/Description:
TYPE III G. OTHER NON-CONV. TRENCH SYSTEMS
Saprolite System? '.,Yes X, No
*Distribution Type: GRAVITY -SERIAL Pump Required?
0 Yes X No,
*Pre -Treatment:
Drain field
1 a 0 0 Sq. ft.
a
304ft.
9 0Inches O.C.
(9 Feet O.C.
3 Olnches
(9 Feet
inches
Minimum Trench Depth:
3
6
Inches
Minimum Soil Cover:
a
4
Inches
Maximum Trench Depth:
3
6
Inches
Maximum Soil Cover:
)
4
Inches
Page 1 of 4
*System Type: INFILTRATOR QUICK STANDARD
Installer: Sherman Dunn
Certification #: 2702
*EHS: 2140 - Nations, Robert
Date: 0 5/ 1 1/.1 0 1 7
Approval Status
X❑ Approved ❑ Disapproved
CDP File Number 237709 - 1
Manufacturer: shoat
STB: 1000
Gallons: 1000
Date:
0
a/
a 8/
a 0 1 7
*Filter Brand:
POLYLOK
PL -122 With Pipe Adapter
ST Marker:
❑
Yes
❑X
No
Reinforced Tank:
ElYes
\ 1 Piece Tank:
❑X
No
\
\Piece Tank:
❑
Yes
❑X
No
Manufacturer:
PT:
Gallons:
Pump Type:
Date:
/
Riser Sealed
❑
Yes
Riser Height:
❑
Yes
Reinforced Tank:
❑
Yes
\ 1 Piece Tank:
❑
Yes
/ Pipe Size:
Pipe Length:
*Schedule:
Pressure Rated ❑ Yes
Approved fittings ❑ Yes
County ID Number: 5778374515
septic i anK
Lat.
❑ No
❑ No (Min. 6 in.)
❑ No
❑ No
Long:
In
Installer: Sherman Dunn
Certification #: 2702
*EHS: 2140 - Nations, Robert
Date: 0 5/ 1 1/ x 0 1 7
Approval Status
❑X Approved ❑ Disapproved
Pump Tank
Installer:
Certification #:
*EHS:
Date:
Approval Status
❑ Approved ❑ Disapproved
Supply Line
inch diameter Installer:
feet Certification #:
*EHS:
❑ No Date:
❑ No Approval Status
❑ Approved ❑ Disapproved
/
Pump Type:
Dosing Volume:
-
Draw Down:
Inches
*Chain:
Valves Accessible
❑
Yes
❑
No
Flow Adjustment Valve
❑
Yes
❑
No
Check -valve
❑
Yes
❑
No
PVC Unions
❑
Yes
❑
No
Vent Hole
❑
Yes
❑
NO
Anti -siphon Hole
❑
Yes
❑
No
Installer:
Gal Certification #:
*EHS:
Page 2 of 4
Date:
Approval Status
❑ Approved ❑ Disapproved
CDP File Number 237709 - 1
NEMA 4X Box or Equivalent ❑ Yes
Box 12 inches Above Grade ❑ Yes
Box Adj. To Pump Tank ❑ Yes
Conduit Sealed ❑ Yes
Pump Manually Operable ❑ Yes
*Activation Method:
Alarm Audible ❑ Yes
Alarm Visible ❑ Yes
*Operation Permit completed by_
Authorized State
Owner/Applicant Signature:
County ID Number: 5778374515
❑
NO
Installer:
❑
No
Certification #:
❑
No
❑
NO
*EHS:
❑
No
Date:
Approval Status
El
No
ElApproved
❑ Disapproved
El
No
2140 - Nations, Robert
Date of Issue: 0 5/ 1 1/.1 0 1 7
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 iii G. sewage septic system.
Rule .1961 requires that a Type TYPE iii G. septic system meet the following criteria:
Minimum System Review By The 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 for a 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 for a 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.
9 Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 3of4
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC
Drawing Drawing Type: Operation Permit
CDP File Number: 237709 - 1
County File Number: 5778374515
27028 Date: / /
O Inch
Scale: O Block
O N/A
Page 4 of 4 P1 P2 P3
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC
CDP File Number:
27028 County File Number:
Date:. . /
Click below to import an image from an external location: Drawing Type: Operation Permit
5778374515
Page 4 of 4 P1 P2 P3
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Supply Line:
Pump Requirements:
Electrical Equipment:
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