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121 Lost Farm Dr Lot 30 OPERATION PERMIT or ice useOnly., Davie County Health Department "CDP:FIle Number 138626 1 33 210 Hospital Street 5880-511-w(3970 .` 3 P.O.Box 848 County ID Number" °- Mocksville NC 27028 Evaluated For;:EXPANSION Phone:336-753-6780 Fax: 336-753-1680 Township Applicant: Larry L. and Elizabeth L. Fincher rm perty Owner: Larry L. and Elizabeth L. Pincher Address: 121 Lost Farm Drive ddress: 121 Lost Farm Drive CRY: Advance City: Advance State/Zip: NC 27006 State/Zip: NC 27006 Phone#: (336) 998-6453Phone#: (336) 998-6453 Property Location & Site Information Address/Road#: Subdivision: Magnolia Acres Phase: Lot: 30 121 Lost Farm Rd Advance NC 27006 Directions Structure: SINGLE FAMILY Hwy 64 East,-turn left on Hwy 801, go-to-2nd-Peoples Ck Rd. in Advance. Left into Magnolia Acres, right on #of Bedrooms: 4 Tulip Magnolia. Left on Twisted Hill, Rit on Lost Farm #of People: `Water Supply: PUBLIC *IP Issued by. 'System Classification/Description: TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) `CA issued by: 2140-Nations,Robert Saprolite System? OYes @No Design Flow: 4 8 0 `Distribution Type: GRAVITY-SERIAL Pump Required? OYes QNo Soil Application Rate: 0 a 7 5 =Pre Treatment: Drain field rNo. on Field Sp.ft. `System Type: INFILTRATOR QUICK 4 STANDARD Lines installer: Randy Miller and Son Total Trench Length: 1 0 0 ft• Certification#: Trench Spacing: — Olnches O.C. Feet O.C. EH S: 2140-Nations,Robert Trench Width: - ()Inches Feet Date: 0 7 / 1 0 / .2 0 1 4 Aggregate Depth: inches Minimum Trench Depth: Inches Minimum Soil Cover. Inches Approval Status Maximum Trench Depth: ® ApprOVed Disapproved Inches Maximum Soil Cover: Inches CDP File Number 138626 - 1 Septic Tank County ID Number: 5880-51-6970 Manufacturer. Lat. - Long: STB: Gallons: Installer: Date: / Certification#: "EH S: 'Filter Brand: Date: ST Marker: ElYes ❑ No A royal Status, Reinforced Tank: ❑ Yes ❑ NO pp = 1 Piece Tank: ❑ Yes ❑ No ❑ �►pproved❑ Disapproved r Pump Tank Manufacturer. Installer: PT: Certification#: Gallons: `EH S: Date: - /-— -----/ _ Date:--- ----/-----/ ----- - -- Riser Sealed ❑ Yes ❑ No Riser Height: ❑ Yes ❑ No (Min.6in.) "t,, ' tip. yApproval Status y Reinforced Tank: ❑ Yes ❑ No 4, ❑f A yroveaO Dlsapproyed 1 Piece Tank: ❑ YeS ❑ NO `� " �' Supply Line CPipe Size: inch diameter Installer. Pipe Length: feet Certification#: *Schedule: *EH S: Pressure Rated ❑ Yes ❑ No Date: Approved fittings ❑ Yes ❑ NO Approval Status s` ❑rApproved[ Disapproved ' 3 Pump Requirement r Pump Type: Installer: sing Volume: - Gal Certification#: Draw Down: Inches "EHS: "Chain. . Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check-valve ❑ Yes ❑ No h gpproval Status PVC Unions ❑ Yes ❑ No ❑ Approved❑ Disapproved Vent Hole Yes ❑ ❑ No Fr; Anti-siphon Hole ❑ Yes ❑ NO • CDP File Number 138626 - 1 5880-51-6970County ID Number: Electric Equipment rNEMA4X 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 *ENS: Pump Manually Operable ❑ Yes ❑ No *Activation Method: Date: $" { Nr� L,Approval Status ,; $ ,s Alarm Audible ❑ Yes ❑ No Alarm Visible ❑ Approved Disapproved ❑ Yes ❑ No 2140-Nations,Robert *Operation Permit completed by: Authorized State Agent: Date of Issue: 0 7 1 0 0 0 1 4 This system has been installed in compliance with applicable NC General Statutes:Article 11, Chapter 130A, Rules for Treatment and Disposal,15A NCAC 18A.1900 et.Seq., and all conditions of the Improvement Permit 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: 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 fora 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 ownerand a management entity priorto the issuance of an Operation Permit fora 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 for maintenance and operation, responsibilities of the ownerand systems operator,provisions thatthe contract shall be in effect(oras 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 Olmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT 138626 - 1 Davie County Health Department CDP File Number: 210 Hospital Street 5880-51-6970 P.O. Box 848 County File Number: Mocksville NC 27028 Date: ! / Olnch Drawiing Drawing Type: Operation Permit Scale: . OBlock ON/A -bat r d a a j, ,OLS � k ___ n r CONSTRUCTION For office use only AUTHORIZATION *CDPFile Number ,: 38626 1 °= Davie County Health Department County ID Number ., 51 6970 210 Hospital Street Evaluated For EXPANSION P.O. Box 848 '�..».►' Township Mocksville NC 27028. PERMIT VALID UNTIL: Phone:336-753-6780 Fax:336-753-1680 0 6 1 8 .1 0 1 9 Applicant: Larry L.and Elizabeth L. Fincher Property Owner: Larry L.and Elizabeth L. Fincher Address: 121 Lost Farm Drive Address: 121 Lost Farm Drive City: Advance City: Advance State/Zip: NC 27006 State/Zip: NC 27006 Phone#: �(336) 98-6453 Phone#: �(336)�998-64�53 Property Location & Site Information Address/Road#: Subdivision: Magnolia Acres Phase: Lot: 30 121 Lost Farm Rd Advance NC 27006 Directions Structure: SINGLE FAMILY Hwy 64 East,turn left on Hwy 801, go to 2nd Peoples Ck Rd. in Advance. Left into Magnolia Acres, right on Tulip #of Bedrooms: 4 Magnolia. Left on Twisted Hill, Rit on Lost Farm #of People: *Water Supply: PUBLIC System Specifications Minimum Trench Depth: a 4 r ssification: Provisionally suitable Inches Minimum Soil Cover:System? OYes ' 9No Inches ow: 4 8 0 Maximum Trench Depth: 3 6 inches Soil Application Rate: 0 3 Maximum Soil Cover: oZ 4 Inches *System Classification/Description: *Distribution Type: GRAVITY-SERIAL TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: Gallons *Proposed System: 25%REDUCTION 1-Piece: O Yes ®No Pump Required: OYes (&No O May Be Required Nitrification Field 3 0 0 Sq.ft. Pump Tank: Gallons No. Drain Lines 1 1-Piece: OYes (&No Total Trench Length: 1 0 0 GPM--vs-- ft. TDH ft. Trench Spacing: Inches O.C. 9 2 Feet O.C. Dosing Volume: _ Gallons Trench Width: — 3 O Inches ®Feet Grease Trap: Gallons Aggregate Depth: inches Pre-Treatment: O NSF OTS-1 OTS-II Septic Tank Installer Grade Level Required: 01011 O III ON Page 1 of 3 Y CDP File Number 138626 - 1 County ID Number: 5880-51-6970 ❑ Open Pump System Sheet Repair System Required:OYes ONO ONO, but has Available Space CDesign ystem Trench Spacing: 9 O Inches O.C. fication: Provisionally suitable — ®Feet O.C. Trench Width: Q Inches : 4 8 0 _ 3 ®Feet Soil Application Rate: 0 3 Aggregate Depth: inches Minimum Trench Depth: a 4 Inches *System Classification/Description: TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Minimum Soil Cover. LESS) 1 a Inches Maximum Trench Depth: 3 6 Inches *Proposed System: 25%REDUCTION Nitrification Field 1 6 0 0 Sq. Maximum Soil Cover: a 4 ft, Inches No. Drain Lines 4 *Distribution Type: GRAVITY-SERIAL Total Trench Length: 4 0 0 ft. Pump Required: OYes ®No O May Be Required Pre-Treatment: O NSF OTS-I OTS-II *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. frihmarning 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. Ch—b" 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(A 937(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. Signatur Date: 0 6 / 1 8 / .2 0 1 4 *Issued By: 2140-Nations,Robert Date of Issue: 0 6 / 1 8 / a 0 1 4 Authorized State Agent: `' �Y1 1 ' Malfunction Log OYes ®Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION 138626 - 1 Davie County Health Department CDP File Number: 210 Hospital Street 5880-51-6970 P.O.Box 848 County File Number: Mocksville NC 27028 Date: 0 6 / 18 a 0 14 0 Inch Drawing Drawing Type: Construction Authorization Scale: . O Block 0 N/A V' ab IL YV YJ Mr Qi L b e V f Page 3 of 3 P1 P2 � 6 4 -04 060 err When qou 00 Ovd APPLICATION FOR SITE EVALU "I'ION/IMPMOVEIVIENT PERMIT& ATC `sem Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 , A (336)753-6780/Fax(336)753-1680 Date: Received `' Applicatio a o mprovement Permit ❑Authorization To Construct(ATC) ! Both Type of Application: ❑New System ❑Repair to Existing System VrExpansion/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 Z, V-, ,2AALTLi G. 'C-1iJaenC Contact Person L �� - Address /ai/ GosTFis.Pm 1�K. Home Phone City/State/ZIP AJC- 'C 0G Business Phone Email I/, 6a Name on Pe it/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) . Owner's Name 51-L Phone Number Owner's Address City/State/Zip Property Address City Lot Size �}GRQj Tax PIN# 58805/G97� Subdivision Name(if applicable)yOJIA/4C_9eti Section/Lot# 50 Directions To Site: -Pe-,Ole-j C9gZ& Za Z,-P/ 'l. t .,o4a t'I��rvo%'Q Acap/1� . R7' os� T/�fl1g�"1 A . L.B-C7'p.� rwi3/�d1 �[�i�l Du Zig iZ7 ' M y 164-f Specify Problem Occurring: IF RESIDENCE FILL OUT THE BOX BELOW #People Z #Bedrooms �_ #Bathrooms 3% Garden Tub/Whirlpool ❑Yes ANO Basement: XYes ❑No Basement Plumbing: MYes ❑No 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:,(Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: County/City Water ❑New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes XNo 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 corners and locatingd flagging ors king t e house/facility location,proposed well location and the location of any other amenities. r Property o is or owner's legal representative signature Site Revisit Charge Date(s): Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# 3 Revised 11/06 Invoice# i CATION ITE EVALUATION/IMPROVEMENT PERMIT & ATC OCj $ 2001 Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 n LIN (336)751-8760/Fax(336)751-8786 App " ion For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***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 S ��. — C;, �, -� . �� : Contact Person 4�. _ Billing Address f ZQ % 1 L q t,J Home Phone City/State/ZIP /-?, .,,. ;) „> _ c- i o i Business Phone Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility orners Flagged NOTE: A survey plat or site plan must accompany this application. Included: Poglie Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name c��. _ C„ s , _ �-. „ Phone Number_ 3 S- o 0 1,., Owner's Address City/State/Zip Property Address_12I_ o S- �a�,. p City -�A ,, _ , , Lot Size 2 . S __ Tax PIN# T1s S o S1 bel'76 Subdivision Name(if a plicable) /'►'�R , ^ o I; _ /� Section/Lot# 3 O Directions To Site: ;-4- g f If the answer to any of the following questions is"yes",supporting documentation must We attached. Are there any existing wastewater systems on the site? ❑Yes [ Wir Does the site contain jurisdictional wetlands? ❑Yes 93do Are there any easements or right-of-ways on the site? ❑Yes CN15 Is the site subject to approval by another public agency? ❑Yes Clido Will wastewater other than domestic sewage be generated? ❑Yes 9N5 IF RESIDENCE FILL OUT THE BOX BELOW #People 2 #Bedrooms 3 #Bathrooms . S Garden Tub/Whirlpool ❑Yes ZAFcri Basement: ids ❑No Basement Plumbing: X?7es ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals a Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: ##Seats Type system requested:, PConventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: WCounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 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 corners and locating and flagging or staking the house/facility location,proposed well location and the location of any other amenities. Site Revisit Charge ro owner's or owner's legal representative signature Date(s): 7 Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# R9,�2a g3 Revised 11/06 Invoice# � " / r 1 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O,Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account M 989900093 Tax PIN/EH#: 5880-51-6970 Billed To: Shelton Construction Services Subdivision Info: Magnolia Acres Lot#30 Reference Name: Location/Address: lost Farm Drive-27006 Proposed Facility: Residence Property Size: 2.5 acres ATC Number: 4771 Site Type-,.2<ew ❑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 2.5 #People Basement❑ Basement plumbiwa--, i Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size 7` �"`2 Type of Water Supply, 0' ounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD)LoOTank SizeJ9Q03AL.Pump Tank GAL. n Trench Widthtt Max.Trench Depth �, Rock Depth i 2� Linear Ft. L166 Site Modifications/Conditions/Other: I Contact the Davie County Environmenta Health Section for final inspection of this system between 8:30-9: a.m.on the day of installation. Telephone#(336)751-8760. iJE 40 As stated In 15A NCAC 18ki969(5) accepted Systems may also be used 7r- o , S•AM 0. i �� t Environmental Health Sp ialist Date: 40D DCHD 11/06(Revised) , DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 f�G( (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT I21 Lo-s4 PArnl D62-'l t I Account #: 989900093 Tax PIN/EH#: 5880-51-6970 Billed To: Shelton Construction Services Subdivision Info: Magnolia Acres Lot#30 Reference Name: Location/Address: Lost Farm Drive-27006 Proposed Facility: Residence Property Size: 2.5 acres ATC Number: 4771 **NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC has been installed in compliance with Article 11 of G.S.Chapter 130A, Section.1900"Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. System Type: S.T.Manufacturer a0FTank Date- Tank Sized Pump Tank Size- System Installed By: C� //��/� E.H. Specialist: 6,yy,,Vr7Date: 57 / a pownil 3 Adrooms 3&6\ 37c k fla vs a . �C[j ,e DCHD 11/06(Revised) GoMAPS -Davie County NC Public Access Page 1 of 1 Davie County, NC - GIS/Mapping System Qac Click Here To Start Over Quick Search:(County ID c ✓" ✓ ! Active Layer. r Use Map Tres GIS �UU K Ell PARCELS(Map Tips Available} ....._ _ _ .. Map Layers I Results 209 326 m C, L 1. C-1 a en CO m o m M C rn 329 207 - =o LOST FARM DR j http://maps.co.davie.ne.us/GoMaps/map/Index.cfm?maimnapservice=gomaps&CFID=41... 10/19/2007 �`.; ` �.� ,A----. - """"" _. . .. - _ _ .1 _ ---� -- _ _ ..-. ._�...-�. .. r� - , � , �� , - _._ __ ... _ _ . _ _ # _ s. _._.. . _ �...-_ __ _ . _ ,..� , _ . _ _ _ _ _ _ _ .. _ _ , ,-- - - - ._.- - - - _ . . _ _ . . . . __ _ .- -- - — -- __ _ _ _._,,�. .. . - __.... _ __ _._ _ _ _. . _ .. _ �.._ __ � _ . . _ _ .. __ - - . .� . � _ -- --- --- -'�..-. � � � r . . 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