112 Star Magnolia Dr Lot 23 JCONSTRUCTION For Office Use Only
' '
AUTHORIZATION "CDP File Number 220015-11
Davie County Health Department County ID Number:
210 Hospital Street Evaluated For. NEW
.� ,,. P.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 0 6 / a 8 / 2- 0 a __1 .. _
Applicant: Shelton Construction Property Owner: Jesse Carter
Address: 1257 US Hwy 64 W Address: 126 Southern Magnolia
CRY: Mocksville City: Advance
StatefZip: NC 27028 StatelZip: NC 27006
Phone#: (336)345-2006 Phone#:
Property Location & Site Information
Address/Road#: Subdivision: Magnolia Acres Phase: Lot: 23
112 StarR Magnolia Drive
Advance NC 27006 Directions
Hwy 801 to Peoples Creek Rd. beside Flower Shop 1 mile
_'Structure: SINGLE FAMILY on left
#of Bedrooms: 4
#of People:
'Water Supply: PUBLIC
System Specifications
Minimum Trench Depth: a 4
rDneisignn
sification: Provisionally suitable Inches
System? Yes Minimum Soil Cover.
y Q r�lo Inches
ow: 4 8 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 . a 7 5 Maximum Soil Cover. Inches
'System Classification/Description: 'Distribution Type:
TYPE 11 A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
1 0 0 0 _ Gallons
'Proposed System: 25%REDUCTION 1-Piece: Oyes @No
Pump Required: OYes QNo OMay Be Required
Nitrification Field - 1 7 4 5
5q. ft. Pump Tank: Gallons
No. Drain Lines 5 1-Piece: QYes @No
Total Trench Length: 4 3 6 ft. GPM—vs— ft. TDH
Trench Spacing: _ 9 . Feet O C.nches C Dosing Volume: _ Gallons
Trench Width: — 3 @Inches
Feet Grease Trap: Gallons
Aggregate Depth: inches Pre-Treatment: ONSF OTS-1 OTS-II
Septic Tank Installer Grade Level Required: 01 011 OIII OIV
DaAA 'I A�Z
CDP File Number 220015 - 1 County ID Number.
❑ Open Pump System Sheet
Repair System Required:@Yes ONO ONO, but has Available Space
rDesign
System
Trench Spacing: 9 Q Inches O.C.
ification: Provisionally Suitable — Feet O.C.
Trench Width: Inches
w: 4 8 ® — . 3 . Feet
Aggregate Depth:
Soil Application Rate: 0 2 7 5 inches
Minimum Trench Depth: a. 4
*System Classification/Description: Inches
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS, Minimum Soil Cover. 1 a inches
- Maximum Trench Depth: 3 6
*Proposed System: 25%REDUCTION
Inches
Maximum Soil Cover: 2 4
N�rification Field _ �_ Inches
4 8 0 Sq.ft.
No. Drain Lines *Distribution Type: GRAVITY-SERIAL
5
�-TotalTrench Length: 4 3 6 Pump Required: OYes ONo (j)May Be Required
ft
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 for wastewater System Construction shall bevalld fora person equal to the perlod of validity of the improvement Permit,not
to exceed five years,and may be Issued atthe same time the Improvement Permit issued(NCGS 130A-33G(b)).If the installation has not been
completed during the period of validity ofthe 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 ONO
Applicant/Legal Reps. Signature: Date:_
*Issued By: 2140-Nations,Robert Date of Issue: . 0 6 / a 8 / 2 0 1 6
Authorized StateAge Malfunction Log OYes f
,&Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department CDP File Number:
210 Hospital Street
P.O.IBox 848 County File Number:
Mocksville NC 27028 Date: 0 6 / .1 8 / .2 0 1 6
Q Inch
Drawing Drawing Type: Construction Authorization Scale: . QBlock
QN/A
- Q
_LL
I l I
• I I 1 I L._._.—j
- -
-I I
_l � �� I i ►_.� 1 f l � l
..........
.........
C....................L
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street CDP File Number:
P.O.Box 848
Mocksvilie NC 27028 County File Number:
Date: . ' .6.l 28 / a 0 6
Click below to import an image from an external location: Drawing Type:Construction Authorization
-IMPROVEMENT PERMIT For Office Use oniv
RCDP File Number 220015-1
Davie County Health Department
210 Hospital Street County ID Number.
P.O. Box 848 Evaluated For NEW
Mocksville NC 27028 Township:
Phone:336-753-6780 Fax:336-753-1680 pERhIIT VALID UNTIL 6/28/2021 -
*NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit.
Applicant: Shelton Construction ry
pertyOwner. Jesse Carter
Address: 1257 US Hwy 64 W dress: 126 Southern Magnolia
Cay: Mocksville : Advance
State/Zip: NC 27028 State0p: NC 27006
Phone#: (336)345-2006 1Phone#:
Property Location & Site Information
_ Address/Road#: - Subdivision: Magnolia Acres Phase: Lot: 23
112 Stare Magnolia Drive
Advance NC 27006 Directions
Structure: - SINGLE FAMILY Hwy 801 to Peoples Creek Rd. beside Flower Shop
#of Bedrooms: 4 1 mile on left
#of People:
*Water Supply: PUBLIC
System Specifications
nit�ial System_
*Site ,asC'1 sification: Provisionally Suitable
Minimum Trench Depth: 2 4 Inches
Saprolite System? OYes @No Maximum Trench Depth: 3 6
Inches
Design Flow: 4 8 - 0 Septic Tank:
1 0 0 0 Gallons
Soil Application Rate: 0 .2 7 5 1-Piece: OYes QNo
u Pump Required: OYes ®No O May Be Required
*System Classification/Description:
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons
LESS)
*Proposed System: 25%REDUCTION 1-Piece: OYes ONo
Repair System Required:OYes ONO ONo, but has Available Space
Repair System
*Site Classification: Provisionally Suitable Minimum Trench Depth: 2 4 Inches
Soil Application Rate: 0 a 7 5 Maximum Trench Depth: 3 6 Inches
*System Classification/Description: Pump Required: OYes O No ®Maybe Required
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR
LESS)
*Proposed System: 25%REDUCTION
Page 1 of 3
CDP File Number 220015- 1 County ID Number:
'Site Modifications p Open Fill Sheet
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 by the Health Department in noway guarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements. - -- ;
Slte Plan 'fie I nprovement Permit shall be valid for 6 years from date of issue with a site plan(means a drawing not necessarily drawn to
scale that shows the existing and proposed property lines with dimensions,the location of the facility and appurtenances,the
site for the proposed Wastewater system,and the location of water supplies and surface waters).
Plat The Improvement Permit shall be valid without expiration with plat(means a property surveyed prepared by a registered land
surveyor,drawn to a scale of one inch equals no morethan 60 feet,that Includes:the specific location of the proposed facility
O and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters. Plat
-- also means,for subdivision lots approved by the local planning authority and recorded with the county register of deeds,a copy
of the recorded subdivisions platthat is accompanied by a site plan that Is drawn to scale).
The Department and Local Health Department may impose conditions on the issuance and may revoke the permits for failure of
the system to satisfy the conditions,the rules,or this article.This permit is subject to revocation if the site plan,plat,or intended
use changes(NCGS 130A335(f)).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,
reputing,and repair(.1938(b)}
Applicant/Legal Reps.Signature Required? Oyes ONO
Applicant/Legal Reps. Signature, Date:
"Issued By: 2140-Nations,Robert Date of Issue: 0 6 / 2 8 / 2 0 1 6
OValid without Expiration?
Authorized State Agent: &Create CA?
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
IMPROVEMENT PERMIT 220015 - 1
Davie County Health Department CDP File Number:
210 Hospital Street
P.O.Box 845 County File Number:
Mocksville NC 27025 Date:
---
0 Inch
Drawing Drawing Type: Improvement Permit Scale: OBlock
ONlA
L%A I
I
.,_.5--7
I
Ll
I I L 1. -L-L I __lam)I I i I I I I ._: I I .. ! ►
IMPROVEMENT PERMIT
Davie County Health Department
210 Hospital Street CDP File Number: 220015- 1
P.O.Box W
Mocksvitle NC 27028 County File Number:
Date: 06 / 28 / 2016
Click below to-import an image from an external location:Drawing Type: Improvement Permit
21 �a
f1 35
,C AWS E_ `9
�l
e IZ
Sale 1 = 3D' .
1
f
� I
1,
ION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC
vn'�X Davie County Environmental Health
i� -
P.O.Box 848/210 Hospital Street '
Mocksville NC'27028
(336)753-6780/Fax(336)753-1680
Application For: 7 Site Evaluation/Improvement Permit C Authorization To Construct(ATC) ❑Both
Type of Application: ❑New System ❑Repair to Existing System DExpansion/Modification of Existing System or Facility
***IMPORTANT***THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name SA'l r� �� ��r-�_�: Contact Person 4!f
Address 1 2—C-7 U i )+w Y G`f w Home Phone
City/State/ZIP —ks —• 11 c ^/L v 2Y Busness Phone 3 3 y —20 o to
Email G o I1 S k {-o s Email:
Name on Permit/ATC if Different than A ve
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Comers Flagged
NOTE: A survey plat or site plan must accompany this application. Included:U Site Plan UPlat(to scale)
(Permit is valid for 60 months 'th site plan,no expiration with complete plat.)
Owner's Name—�� -r-- .�r'}-c — Phone Number
^. Owner's Address-1 Z,lo
1`V — c-- 2 0
PropertyAddress ity
Lot Size 7 0 Tax PIN# _
Subdivision Name(if applicable) . 4 .t*, jrcrartion/Lot# '2
Directions To Site: SQ I tf-� c /mss,; C�-.. �IL �• ,l . / � ` i— `
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 I.i11
Does the site contain jurisdictional wetlands? Yes kKo
Are there any easements or right-of-ways on the site? _Yes &�fIQo
Is the site subject to approval by another public agency? Yes "'K
Will wastewater other than domestic sewage be generated? Yes E` -
IF RESIDENCE FILL OUT THE BOX BELOW
#People #Bedrooms #Bathrooms _Garden Tub/Whirlpool wffes INo
Basement:DYes fr o Basement Plumbing: DYes
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: Lgm%entional ❑Accepted 01nnovative ❑Alternative ❑Other
Water Supply Type: ounty/City Water ❑New Well ❑Existing Well 7 Community Well _
Do you anticipate additions or expansions of the facility this system is intended to serve?C YesO
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 rules.
I understand that I am responsible for the proper identification and labeling of property lines and comers and locating and flagging
or s1 a house/facility 'localn,propose yell location and the location of any other amenities.
�� Site Revisit Charge
Pro oxvmer' oor oHmer's legal representative signature
L Date(s):
Z Client Notification Date:
Date EHS:
Sign given i Yes ONo Account#
Revised 11/06 Invoice#