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188 Primrose Rd Lot 12 'OPERATION PERMIT ° or ice se n Davie County Health Department *CDP FiId Numtrer 175870 1 210 Hospital Street st8e-85.5704, P.O.Box 84$ County ID Number: Mocksville NC 27028 Evaluated For: NEW Phone:336-753.6780 Fax:336»753-1680 Townships Applicant: Dick AndersonProperty Owner. Dick Anderson Address: 225 Winghaven Lane Address: 225 Winghaven Lane City: Advance, City: Advance State2ip: NC 27006 State/Zip: NC 27006 Phone#: (336)492-7579 Phone#: (336)492-7579 -- Property Location & Site Information Address/Road#: Subdivision: Marchwoods Phase: Lot: 12 188 Primrose Road Advance NC 27006 Directions Structure: SINGLE FAMILY 1-40 East to Hwy 801 turn left on Peoples Creek Rd, Left on March Ferry left on Primrose #of Bedrooms: 3 #of People: *Water Supply: PUBLIC *IP Issued by. *System Class ification[Description: TYPE 11 A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140 Nations,Robert Saprolite System? QYes ( No Design Flow: 3 6 0 *Distribution Type: GRAVITY-PARALLEL(eq.d-box) Pump Required? QYes j&No Soil Application Rate: 0 2 7 5 *Pre Treatment: Drain field Nilrification Field 1 3 0 9 Sq.ft. *System Type: INFILTRATOR QUICK 4 STANDARD No, Drain Lines 4 Installer: Donnie Lakey Total Trench Length: 3 a 8 g• Certification#: 1108 Trench Spacing: C — 9 (E)Feet 0 C. EH S: 2140-Nations,Robert Trench Width: 3 Inches Feet Date: 0 5 / 0 6 / 2 0 1 5 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. 4Inches Approvat Status Maximum Trench Depth: 3 6 ® Approved® Disapproved . Inches Maximum Soil Caver. a 4 Inches CDP File Number 175870 - 1 County CD Number: 5789.85.5704 Septic Tank Manufacturer. Shoaf Let. , STB: 760 Long: Gallons: laao Installer oonnis Lakey Date: 0 1 / 0 9 / 2 0 1 5 Certification#» 1108 'EHS: 2140-Natksti Rout *Fitter Brand: POLYLOK PL-122 With Pipe Adapter ST Marker. 11 Yes 0 No Date: 0 5 / 0 6 / x 0 1 5 Appravei StaFus Reinforced Tank: ❑ Yes ❑ No ❑ Yes Q No � /�Approued�] Dtsappro�red�- 1 Piece Tank: Pump Tank Manufacturer. Installer PT: Certification#: Gallons: THS: S: Date: / / - Date: RiserSealed ❑ Yes ❑ No Riser Height: ❑ Yes ❑ No (Min.6 in.) einforced Tank: ❑ Yes ❑ N O ❑ ApprovedCl ©tsapprorred 1 Piece Tank: ❑ Yes ❑ NO Supply Line FPipeize: inch diameter installer gth: feet CertificationSchedule: *EHS: Pressure Rated ❑ Yes ❑ No Date: Approved fittings ❑ Yes ❑ NO AprertatSius'` �� pK /'❑' ppro�ed❑�D�sa�proYed �� Pump Mquir—emot Pump Type: Installer. Dosing Volume: — Gal Certification g: Draw Down: Inches *EHS: *Chain: Date: Valves Accessible ❑ Yes ❑ NO Flow Adjustment Valve ❑ Yes ❑ No Check-valve ❑ Yes ❑ No2-5 APpNOW raval'Status f PVC unions ❑ Yes ❑ No ❑ Approved❑ Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ Yes 0 NO CDP File Number 175$70 - 1 County ID Number: 5789-85-5704 Electric Equipment NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer. Box 12 inches Above Grade E) Yes ❑ No Certification#: Box Adj.To Pump Tank ❑ Yes ❑ No Conduit Seated ❑ Yes ❑ No THS: Pump Manually Operable ❑ Yes ❑ No 'Activation Method: Date: Appravat Status Alarm Audible ❑ Yes ❑ No Approved❑ Disapproved Alarm Visible ❑ Yes ❑ NO 2140•Nations.Robert 'Operation Permit completed by: Authorized State Agen Date of Issue: 0 5 / 0 6 / 2 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.,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 it A. septic system meet the following criteria: Minimum System Review By The Local Health Department: NIA Management Entity: OWNER _ Minimum System Inspection/Maintenance Frequency ByCertified Operator. NIA 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 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 fora homelbusiness owner must maintain avalid 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 Olmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT 175870;- 1 Davie County Health Department CDP File NuYnber: . 210 Hospital Street 5789-85-5704 P.O.Box 848 County File Number: Mocksville NC 27028 Date: I Q Inch Drawing Drawing Type: Operation Permit Scale. . • OBlo k 1 —Tq1 4 C IF ---F- I - CONSTRUCTION For Office Use only AUTHORIZATION *CDP Fite Number 175870-1 Davie County Health Department County ID Number. 5789-85-5704 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 1 a / 0 9 a 0 1 9 Applicant: Dick Anderson r pertyOwner: DickAnderson Address: 225 Winghaven Lane dress: 225 Winghaven Lane City: Advance City: Advance State/Zip: NC 27006 State/Zip: NC 27006 Phone#: (336)492-7579 Phone#: (336)492-7579 Property Location 8 Site Information rAddress/Road#: Subdivision: Marchwoods Phase: Lot: 12 188 Primrose Road Advance NC 27006 Directions Structure: SINGLE FAMILY 140 East to Hwy 801 turn left on Peoples Creek Rd, Left on March Ferry left on Primrose #of Bedrooms: 3 #of People: 'Water Supply: PUBLIC System Specifications Minimum Trench Depth: a 4 rDesigan ssification: Provisionally Suitable Inches Minimum Soil Cover. 1 a System? QYes ®No Inches low: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 1 7 5 Maximum Soil Cover: a 4 Inches "System Class ification/Description: "Distribution Type: GRAVITY-PARALLEL(eq.d-box) TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0' 0 Gallons "Proposed System:25%REDUCTION 1-Piece: Q Yes Q N o Pump Required: QYes ®No OMay Be Required Nitrification Field 1 3 0 9 Sq.ft. Pump Tank: Gallons No. Drain Lines 4 1-Piece:QYes QNo Total Trench Length: 3 a 7 ft GPM—vs— ft. TDH Trench Spacing: _ Feet O.C. g 9 Onches O.C. Dosin Volume: Gallons Trench Width: Inches 3 - @Feet Grease Trap: Gallons Aggregate Depth: - - - inches Pre Treatment: ONSF OTS-1 OTS-11 Septic7ank InstallerGrade Level Required:,Ql OII 0.111 OIV Pflnn 1 of R CDP File Number 175870- 1 County ID Number. 57ss-85=5704 ' ❑ Open Pump System Sheet Repair System Required:Wes ONo ONO, but has Available Space rDesign System Trench Spacing: Q Inches 0. . ification: Provisionally Suitable — 9 Feet O.C. Trench Width: QInches w: 3 6 0 �,_, — 3 . V Feet Soil Application Rate: 0 a Aggregate Depth:7 5 inches .� Minimum Trench Depth: a 4 *System Classification/Description: Inches TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR480.GPD OR LESS) Minimum Soil Cover. 1 a Inches *Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: a 4 Nitrification Field 1 3 0 Inches Sq.ft. No. Drain Lines 4 *Distribution Type: Total Trench Length: 3 a 7 ft. Pump Required: Oyes ONo OMay Be Required Pre Treatment: ONSF OTS-1 OTS-II *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 be valid for a person equal to the period of validity of the Improvement Permit,not to exceed five years,and maybe issued at the sametime the Improvement Permit issued(NCG5130A-336(b)�If the Installation has riot been completed during the period of vaildity of the Construction Permit,the information submitted in theapplication fora permit or Construction Authorization Is found to have been Incorrect,falsified or changed,"the site Is altered,the permit or Construction Authorization shall become Invalid,and maybe suspended"revoked(.1937(g)).The person owning"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 Applicant/Legal Reps.Signature Required? OYes ONO Applicariftegal Reps.Signature: Date: *Issued By: 2140-Nations,Robert Date of Issue: . 1 a / 0 9 / a 0 1 4 Authorized State Agent: Malfunction Log OYeS @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 04 1 CDS Fite Number 175870- 1 County ID Number: 57139-85-57 ❑ Open Pump System Sheet Repair System Required:@Yes ONO ONo, but has Available Space rDesign System Trench Spacing: E*03 Inches 4. . ification: Provisionally Suitable 9 Feet O.C. Trench Width: Inches w: 3 6 0 , — 3 • Feet Soil Application Rate: Aggregate Depth: � a � 5 inches Minimum Trench Depth: a 4 Inches "System Classification/Description: TYPE 11 A.CONV SYSTEM(SINGLE-FAMILY OR480 GPD OR LESS) Minimum Soil Cover: 1 a . Inches "`Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 inches Maximum Soil Cover: a 4 Inches No. Drain Lines 4 Nitrification Field 1 3 0 9 Sq ft "Distribution Type: Total Trench Length: 3 a 7 ftPump Required: @Yes ONo OMay Be Required Pre Treatment: ONSF OTS-1 OTS-II "Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. A "Permit Conditions The issuance of this permit bythe 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. This Authorization for Wastewater System Construction shall bevatid for a person equal to the period of validity of the Improvement Permit,not to exceed five years,and may be issued atthe sametime the Improvement Penult Issued(NCGS 130A-336(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 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 besuspended 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 Applicant/Legal Reps.Signature Required? OYes ONO Applicant/Legal Reps.Signature: Date: „(SSUed By: 2140-Nations,Robert Date of Issue: .1.a . 0 9 a . 0 1 4 Authorized State Agent: Malfunction Log Oyes ®Hand drawing Olmport drawing **Site Plan/Drawing attached.** Page 2 of 3 l CONSTRUCTION AUTHORIZATION 175$70- 1 Davie County Health Department CDP File Number: 210 Hospital Street County File Number: 5789-85-5704 P.O.Box 848 Mocksville NC 27028 Date: 1 a / 0 9 / a 0 1 4 Q Inch Drawing Drawing Type: Construction Authorization Scale: . QBlock QN/A Li � M j �o - ti3 a APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health 4A� .O.Box 848/210 Hospital Street tai Mocksville,NC 27028 �etveab : (336)753-6780/Fax(336)753-1680 Application For: Site aluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Type of-Application: ew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name 0 Contact Person IC 144 Address 2 2 s (i✓( nl G N A Ce N ),-A) Home Phone �4 � y9 Z • 7,Y 7 f City/State/ZIP rM6CIt5 t//L 1. /V C .77/O$ Business Phone.:53& 9'f '72 9�j Email T QA /D Q 2 2 L4 Vffid Lo b.,- Name Name on Permit/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 1)14f K ,VD rie-Sej Phone Number,3� q/ r2 75^7�j Owner's Address NG VeA,7 4 V City/State/Zip a 7/0 l91 Property Address 199, `1'P/ALt fo.5,C eb City/}-oVkpw k- Lot Size t).72 C Tax PIN#5'2,?98,�S70 5/ Subdivision Name(if applicable)WAArIllgoob 57 Section/Lot# Z Directions To Site:"X 4'& JqD Z �*-A V 1., 0 N F of .f? 6aeIt S IZ a ,P IF Specify Problem Occurring: IF RESIDENCE FILL OUT THE BOX BELOW [# eople #Bedrooms _ #Bathrooms_3 Garden Tub/Whirlpool Yes ❑No ❑Yes Woo— Basement Plumbing: ❑Yes ONG— 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: e onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: 2 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 D-N-O— 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 Representat5ve of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws es. I understand that I a responsible for the proper identification and labeling of property lines and corners and to nd flaggin stak' g th ouse/facility location,proposed well location and the location of any other amenities. Pr perty owner'-so r owne s legal representative signature Site Revisit Charge Date(s): f L— Client Notification Date: 'Date — EHS: Sign given ❑Yes ❑No Account# Revised 11/06 Invoice# In : ""jh- C r � Dick ObAli 6 0 Ub N ' S 1-4iJ GJ VJ Vj i 'r Jt✓ t/L1i is f1 ll%A tlr 7Vti - � 4-IQ .7.7o fC: f-P . �.. .. .�.......f., a .._.� -.. �.._..--._.. -__ .__ _. __ APPLICAl10,V EO$SITE EVAU ATION/IMPROVEMM PERMIT&ATC •Davie County Health Departrnent ®t- :Envilvnmental mhaim 6ewan r P.o. Box a48/210 Hospital street Magho-ill4. NC 2793$ (336)751-0760 ••eXZPCRTABT••- THIS APDLICATION CAAWKV BE PROCESSED tAU=S ALL TRS R==RM . 33MIWATI01r IS PRov2sYD. Refer to the-XNMMP=ON B=JaTIN for insttuctiona. ., ✓1. sae. f.bs siljea / t d w.+�tJS T-t!.✓G(�,e,,,t.ct r.r.on8d� ./k,tiiog 11fdr.es (.V/A/(rf4A*;i1z.tl e� V1fw.e►nmw ✓cit?/aute/za /Y1A('�S✓,(cL& Al( ;t70J$ shoo._ `t S 7A 7V y a, near on PemIcIATC if a •grant thm Above M.ilteq address City/State/Zip ,,,—s. Application For: XSito Ibaluation O Iaprovement permit/ASC 0 Both --{. Pro%—t.s...tee,XRnuse 0 Nubile nom* ❑ Business CI Induatry 13 Other ---4. Type ervto requestad. Q eoo•.Atio.aT d eou.e.tional aoditioa ❑ t.owativ. mac. ,11 Xeesideaee, F People F Bodrocim —3— D Bathrooms •1' idDl,WaL.0 l7a.r3ye D1/DaMal LfMael.t�e 7te0►La. ❑DY.r.VPlutsteg ❑nuwet/N.plw.biwg 1. If Duet.ssa/Tnduatty/other: verify typ. A P.0010 t stnko I Camodu a ra.u.ra r urinals ►Wats Cnelers Ir rooDSl>?wcN. 0 seats g.timat.4 ►tate; prig. tg,upn.Per dry) -ra. Typ.of ot.r.opply, GCoua:y/city ❑ well ❑ tbaouwaity S. Do you aetaeipate edduieda or erpansions of the facility this system is intnlded to serve?C)Yes of4o Ifyes,wbatt _ imroarAN7—cutins MUSrCO PLEM THE Rt:QUIRED PROPERTY INFORMATION REQUMED B ElchcraPLATatSPtEPL rfrHESLMHMED by tbed[eat with THIS APPLICATION. Vp►opergyDimensioas: RITEDIRECrIONS(tromModuvltte)torROPERTY: I P2�ycE�(Atte e-Tar omit PIN: a 78 7 d 3 q V .15 158f Sv s � ry _ Properly Address: Road Name v oc�S C2E �Zv C)tyrzp -'0TV-VAy CE A16 J7a,?e f(n s Subd(pidop rovlde Inforttutianl as follotrs: Name•. /4/ec-"&Iona e AWS6 4- Section: Section: Block: Loee---L-A:�23' &-late home eoraerie f1mcd: n-46 r-42 SC r" This is to certify that Ilio(aforaxtilon provided is correct to the best of my knowledge.f understand that any peralit(s) issued hereafter are subject to suspension or revocation.(r the site plans or intended use change,or if the infornution submitted to this appltottoa is falsified orchaucc%l.I,alar, Incarred jro,n this opplicatiom I,hereby,give consent to the Authorized Representative of the Davie County Ilenitb Dcpartinent to enter upon above described property located in Davie County and awned by to conduct all testing procedures as otcatary to determine the site sm / t---DATE .2-��3-O s --S1dNATtJRE THIS AREA MAY BE DEED FOR MMAWIXC YOUR SrM PLAN(Include all of the following: Efisthn and proposed property Bnes and dlmenslons: structures,setbacks, and septic locations). Site RrIlsit Charge Datc(s): Client Notification Date: EHS: Sign even 6 Account No. -2-7. F5 5 Revised DCHD(Q5103 Invoice No.�, - - DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section Soil/Site Evaluation APPLICANT'INFORIVIA,'I IQ1V PROPERTY INFORMATION 2285 Tax PIN/EH#: 5789-97-0344.15 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Phase 4 Lot# 15 Reference Name: ' Location/Address: Peoples Creek Rd.-27006 Proposed Facility: Residence Property Size: see map Date Evaluated: r— Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope% LA HORIZON I DEPTH b^1 Texture group Consistence Structure MincraloEy ' HORIZON II DEPTH 'Leo Texture group Consistence Structure k— Mineralogy HORIZON III DEPTH Texture group :%C_ _ 4- Consistence Structure ASk A, Mineralogy HORIZON IV DEPTH Texture group !_ Consistence WS5 Structure G Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE O•r O• SITE CLASSIFICATION: �� r -a> P4,r-_1'J2A0gVALUATION BY: LONG-TERM ACCEPTANCE RATE: �' OTHER(S)PRESENT: REMARKS: a]LACQ1 Ak qv� &C4, Sr/ W4-L 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 MOW VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm wet NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic r ure 'SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prisipatfc Mineralogy i: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/112