216 Lois Ln� J
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:
Jerry Patton
Address:
P.O. Box 1201
City:
Mocksville
State/Zip:
NC 27028
Phone #:
(336) 284-4372
Address/Road #:
216 Lois Lane
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 2
# of People:
*Water Supply: EXISTING WELL
*IP Issued by: 2140 - Nations, Robert
*CA issued by: 2140 - Nations, Robert
Design Flow: D 4 0
Soil Application Rate: 0 3
Subdivision:
t -or urrlce use unit' -
*CDP File Number 122836-1
L50000001602
County ID Number:
Evaluated For: NEW
township:
,"Property Owner: Jerry Patton
Address: P.O. Box 1201
City: Mocksville
State/Zip: NC 27028
Phone #: (336) 284-4372
Phase: Lot:
Directions
601 S to Gladstone Road left on Lois Lane property
on right
*System Classification/Description:
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
Saprolite System? O Yes (9 No
*Distribution Type: GRAVITY - SERIAL Pump Re uired?
Q Yes RNo
*Pre -Treatment:
i
Nitrification Field 6 0 0 Sq. ft.
No. Drain Lines a
Total Trench Length: a 0 0 ft.
Trench Spacing: 9 _ Qlnches O.C.
9 Feet O.C.
Trench Width: 3 QInches
Feet
Aggregate Depth: inches
Minimum Trench Depth: 3 6
Inches
Minimum Soil Cover:
Inches
Maximum Trench Depth: 3 6 Inches
um Soil Cover:
Inches
Page 1 of 4
*System Type: INFILTRATOR QUICK 4 STANDARD
Installer: Randy Miller
Certification #: 11281
*EHS: 2325 - Mitchell, Brittany
Date: 01/1D/2016
Approval Status
R Approved ❑ Disapproved
CDP Foie Number 122836 - 1
Manufacturer: Shoaf 5f VaK
� Itis
STB: 760
Gallons: 1000
Date:
0
1/
1 1/
2 0 1 6
*Filter Brand:
Riser Sealed ❑
Yes
Riser Height: ❑
Yes
ST Marker:
❑
Yes
❑
No
inforced Tank:
❑
Yes
❑
No
1 Piece Tank:
❑
Yes
❑
NO
❑ Approved ❑ Disapproved
Vent Hole ❑
Yes
❑
Manufacturer:
PT:
No
Gallons:
NO (Min. 6 in.)
Date:
/
Riser Sealed ❑
Yes
Riser Height: ❑
Yes
nforced Tank: ❑
Yes
1 Piece Tank: ❑
Yes
Check -valve ❑
ri
Countv ID Number: L50000001602
Lat.
Pump Tank
❑
No
❑
NO (Min. 6 in.)
❑
No
❑
No
Pipe Size: 3 inch diameter
Pipe Length: 7 feet
*Schedule: 40
Pressure Rated ❑ Yes ❑ No
approved fittings ❑ Yes ❑ No
Installer: Randy Miller
Certification #: 11281
*EHS:
Date:
pply Line
Installer: Randy Miller
Certification #: 11281
'EHS: 2325 - Mitchell, Brittany
Date: 0 1/ l a/ a 0 1 6
Approval Status''
®: Approved "Disapproved`,
//
Pump Type: Installer: Randy Miner
Dosing Volume: - Gal Certification #: 11281
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 ❑
Yes
❑
No
Page 2 of 4
CDP File Number 122836 - 1 County ID Number: L50000001602
Electric Eauiament
NEMA 4X Box or Equivalent
❑
Yes
❑
NO
Installer:
Randy Miller
Box 12 inches Above Grade
❑
Yes
❑
NO
11281
Certification #:
Box Adj. To Pump Tank
❑
Yes
❑
NO
Conduit Sealed
❑
Yes
❑
No
*EHS:
Pump Manually Operable
❑
Yes
❑
NO
*Activation Method:
Date:
ApproVaI,Status ' C
Alarm Audible
El
Yes
El
No
❑,
Approved ❑
Disapproved
Alarm Visible
❑
Yes
❑
No
2325 - Mitchell, Brittany
*Operation Permit completed by:
Authorized State Agent: •✓ Date of Issue:. 0 1 1 a/ a 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 11 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 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.
Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 3 of 4
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Operation Permit
CDP File Number: 122836-1
County File Number: L50000001602
Date: 01 / 1.1/ 2 0 1 6
O Inch
Scale: O Block
O N/A
Page 4 of 4 P1 P2 P3
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 Fax # (336)751-8786
ATC Number: 4710
Site Type: NKew ❑Repair ❑Expansion
**NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A
Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat
or the intended use change.
Residential Specifications: # Bedrooms # Bathrooms I # People Basement❑ Basement plumbing❑
Non=Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size q.131 0-c1rc 5 Type of Water Supply: ❑County/City EiXell ❑Community Well
System Specifications: Design Wastewater Flow (GPD) Tank Size C' GAL. Pump Tank/V/ GAL.
1Trynch Width 3& Max. Trench Depth 3� �Rock Depth I l f Linear Ft,<& 7
I
Site Modifications/Condit$ Other: As stated in 15A INCAC 18A.1969(5
aCCepted Systems may also be use
Contact the Davi Cunty Environmental Health Section for final inspection of this system between
40 9:30a.m. on the day of installation. Telephone # (336)751-8760.
111 is
5
P
a
tf
/%4
Environmental Health Specialist `ins" / :% Date:' 3 -G
DCHD 11/06 (Revised)
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #:
990004356 Tax PIN/EH #: 5736-83-3513
Billed To:
Jerry Patton Subdivision Info:
Reference Name:
Location/Address: Lois Lane -27028
Proposed Facility:
Residence Property Size: 9.231 Acres
ATC Number: 4710
Site Type: NKew ❑Repair ❑Expansion
**NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A
Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat
or the intended use change.
Residential Specifications: # Bedrooms # Bathrooms I # People Basement❑ Basement plumbing❑
Non=Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size q.131 0-c1rc 5 Type of Water Supply: ❑County/City EiXell ❑Community Well
System Specifications: Design Wastewater Flow (GPD) Tank Size C' GAL. Pump Tank/V/ GAL.
1Trynch Width 3& Max. Trench Depth 3� �Rock Depth I l f Linear Ft,<& 7
I
Site Modifications/Condit$ Other: As stated in 15A INCAC 18A.1969(5
aCCepted Systems may also be use
Contact the Davi Cunty Environmental Health Section for final inspection of this system between
40 9:30a.m. on the day of installation. Telephone # (336)751-8760.
111 is
5
P
a
tf
/%4
Environmental Health Specialist `ins" / :% Date:' 3 -G
DCHD 11/06 (Revised)
' Davie County Environmental Health
` P.O. Box,848/210 Hospital Street
Mocksville, NC 27028
(336)751=8760/ Fax (336)751-8786
IMPROVEMENT PERMIT
Account #: 990004356 Tax PIN/EH #: 5736-83-3513
Billed To: Jerry Patton Subdivision Info:
Address: PO Box 1201 Location/Address: Lois Lane -27028
City: Mocksville
Property Size: 9.231 Acres
Reference Name:
Proposed Facility: Residence
**NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An
Authorization To Construct a wastewater system must be obtained from this office prior to the
construction/installation of a wastewater system or the issuance of a building permit(in compliance with
Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to
revocation if site plans, plat or the intended use change.
Permit Type: NIKew ❑Repair ❑Expansion Permit Valid for: U-511"Years ❑No Expiration
Residential Specifications: # Bedrooms_ # Bathrooms I # People Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): oZ ti 0 Type of Water Supply: ❑County/City N<Vell ❑Community Well
Site Modifications/Permit Conditions: As statod in 15A NCAC 18A.1969(5J
=a eepted SySters-mal FAI - rk-as
G7 Iu�PS huy�
Site Plan
9�
O
-,1la
Environmental Health Specialist,
i.p.1.1-06
/46
LTAR
Date
O
r
1
� _
^
fn
Environmental Health Specialist,
i.p.1.1-06
/46
LTAR
Date
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
—APW&NT�N—&W#&O--N Tax PIN/EH #: 5736-�%gM INFORMATION
Billed To: Jerry Patton Subdivision Info:
Reference Name: Location/Address: Lois Lane -27028
Proposed Facility: Residence Property Size: 9.231 Acres Date Evaluated:
Water Supply:
Evaluation By:
On -Site WellC
ommunity
Auger Boring Pi
Public
Cut
FACTORS
1
2
3 4 5 6 7
Landscape position
L
t_
Slope %
HORIZON I DEPTH
Texture group
(_
<,-
Consistence
; ,-
Structure
1c, I`e. ,,
Mineralogy
(
/ t
( i
HORIZON H DEPTH
— d
L -
- A.(
Texture group.L.
t-
L -
5L_
Consistence
Consistence
Structure
Mineralogy
s '
I
HORIZON III DEPTH
- �{
Texture groupL
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATION t� . �/`'r} EVALUATION BY: Tr"t-
ik I`%CC Iy k S
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: c 0!4
REMARKS:
LEGEND
Landscape Position
R - Ridge S - Shoulder ' L - Linear slope FS - Foot slope N - Nose slope
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
33'et
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
Notes
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 - Long-term acceptance rate - gal/day/ft2 DCHD 05105 (Revised)
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�J
-- APP TION FOR SITE EVALUATION/IMPROVEMENT PERMIT
Davie County Environmental Health
QT`�•-�'�'^� �� P.O. Box 848/210 Hospital Street
'� 2001 Mocksville, NC,27028
(336)751-8760/ Fax (336)751-8786
i
&ATC P� POl y
ll� -k
Lh
ment Permit ❑ Authorization To Construct(ATC) k1loth
❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***fPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed Contact Person
Billing Address Me x /.2v 1 Home Phone . 5lr -�,_2$V -Y.5-7.2
City/State/ZIP e Business Phone Sgin C
Name on Permit/ATC if Different than Above
Mailing Address
I' ' �a»1.7111•i�rl�i)7►�:11�1 [���i
City/State/Zip
*Date House/Facility Corners Flawed 5-1-K-0 f
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
(Permit is valid for 60 mon hs with,site plan, a ation with complete plat.)
Owner's Name x�iVlilss p Phone Number534,-.V-YY 3 7,
Owner's Address V 0
Property Address tX /
Lot Size 1, -2- 31 A�
Subdivision Name(if applicable
Directions To Site: %D,
O -- o)e /moi City/State/Zip o
D O;S I•-h%%le City �j�G SJ We
r, Tax PIN# 5736 -S' 3 -- 3S'13
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 W?1(o
Does the site contain jurisdictional wetlands? ❑Yes E
Are there any easements or right-of-ways on the site? ❑Yes 9O
Is the site subject to approval by another public agency? ❑Yes IiWo
Will wastewater other than domestic sewage be generated? ❑Yes gi<o
IF RESIDENCE FILL OUT THE BOX BELOW
n�
# People .112 # Bedrooms _") # Bathrooms _� Garden Tub/Whirlpool ❑Yes ' o
Basement: ❑Yes RrNo Basement Plumbing: ❑Yes EKo
IF NON -RESIDENCE FILL OUT THE BOX BELOW
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; Z- onventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: ❑ County/City Water ❑ New Wellxisting Well ommunity Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 014
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 r
any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation ifthe site is altered, the intended use changes, or if f -
the information submitted in this application is falsified or changed I tc'r&,gjant right of entry to the Authorized Representative
of the Davie County Health Department to conduct necessary"inspectib}'s"ltl determine compliance with applicable laws and rules `; '� �, •,
I understand that I am responsible for the proper identification and labe•Iing of.property lines and comers and locating and flagging
or staking the house/facil' 1 cation, proposed well location and the location of.aAy other amenities.
N.Z/Y t y r
Site Revisit Charge
op ownes or owner's legal representative signature
Date(s):
•� -��-DClient Notification Date:
Date EHS:
Sign given ❑Yes ❑No
Revised 11/06
Account # j
• Invoice # /
- c
------- -----------
.� S 62*57'27"E 716.90'
N 62'00'00'W 3/4" EJP Fnd S 63°00 "E 29.64' . T -Bar w/cap Fnd -
t
208.71'
,Tax Lot ) 6 01
Revised
Z
evised
q\-4 1.000 Acre's g
41ttt
r'"i-S
Revised Lot Lines s" F
for Tax Lot 16.01
217'99'
.S 62°07'35"E IRS Pan9.2311cres+
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IRS 258.76' N 59115103-W V n/f Constance C. Pruitt
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359.65' N 59°12'42" RB 363 0 PG 202
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Tax Lot 18.01"o,o�
Tax Map L-5 \ °e ' ��se o,•<O
n/f Mannie James Graham �o� <ti `� \ r' '` °P\ip
and wife 01 S ®� o s
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----�+ Raf^rPnces dt Notes # 1 & 2.
10
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Tax. Lot, 29`
Tax Map L=
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3/4" EiP Fnd
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Patricia B.
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