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202 Marchmont Dr Lot 21 CONSTRUCTION For Office Use Only
T AUTHORIZATION 'CDP'File Number 197463-1
aid N Davie County Health Department County ID Number.
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 1 0 / 1 5 / a 0 a 0
Applicant: Robert Braswell Property Owner: Robert and Sharon Braswell
Address: 783 Fesmire Street Address: 783 Fesmire Street
CRY: Asheboro City: Asheboro
StatefLip: NC 27203 StatefZip: NC 27203
Phone#: (336)408-3934 Phone#: (336)408-3934
Property Location & Site Information
Address/Road #: Subdivision: Marchamont Plantation Phase: Lot: 21
202 Marchmont Drive
Advance NC 27006 Directions
Structure: SINGLE FAMILY 1-40 exit hwy 801 exit, turn right , to Peoples Creek Rd on
left after crossing RR tracks, Marchmont Plantation on left
#of Bedrooms: 5
#of People:
"Water Supply: PUBLIC
System Specifications
CFlowMinimum Trench Depth: a 4
:
Provisionally Suitable Inches
Minimum Soil Cover. 1 a
OYes OQ No Inches
6 0 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 . a 7 5 Maximum Soil Cover: a 4 Inches
*System Classification/Description: *Distribution Type: GRAVITY-SERIAL
TYPE III A.CONY SYSTEM>480 GPD(EXCLUDING SFD) Septic Tank:
1 a 5 0 Gallons
*Proposed System: 25%REDUCTION 1-Piece: OYes ®No
Pump Required: OYes @No OMay Be Required'
Nitrification Field 8 7 3 Sq. ft. Pump Tank: Gallons
No.Drain Lines a 1-Piece: OYes ONo
Total Trench Length: a 1 8 GPM—vs— ft. TDH
Trench Spacing: 9— ( Inches O.C. —
Feet O.C. Dosing Volume: Gallons
Trench Width: _ 3 2Inches
Feet Grease Trap: Gallons
Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-II
Septic Tank installer Grade Level Required: OI OII 0111 OIV
Donn 1 of l
COP File Number 197463 - 1 County ID Number. T
❑ Open Pump System Sheet
Repair System Required:@Yes ONO ONO, but has Available Space
rDesign
System
Trench Spacing: 9 E03
Inches O.ification: Provisionally Suitable - Feet O.C.
Trench Width: QInches
w: 6 0 0 - . 3 . V Feet
Soil Application Rate: 0 .2 7 5 Aggregate Depth: inches
Minimum Trench Depth: a 4
*System Classification/Description: Inches
TYPE III A.CONY SYSTEM>480 GPD(EXCLUDING SFD) Minimum Soil Cover 1 a Inches
*Proposed System: 25%REDUCTION
Maximum Trench Depth: 3 6 Inches
� -
Maximum Soil Cover: a 4
Nitrification Field a 1 8 a Inches
Sq.ft.
No. Drain Lines 6 *Distribution Type: PUMP TO GRAVITY
' Total Trench Length: 5 4 6 ft Pump Required: @Yes ONo OMay tae 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.
If there isn't enough space to add an additional 1,000 gallon tank and still have fall to the existing septic lines,pump and crash existing tank.Install a
1,250 gallon tank,reconnect to existing septic lines,and add 218 feet of 25%reduction system.
*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 fora 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 130A-336(b)}If the installation has not been
completed during the period of validity of the Construction Perml%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 besuspended or revoked(.1937(8))•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: . 1 0 / 1 6 / 2 0 1 5
Authorized State A - Malfunction Log OYeS
@Hand Drawing Oimport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION 197463 - 1
Davie County Health Department CDP File Number:
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 1 0 / 1 6 / 2 0 1 5
Q Inch
Scale: OBlock
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CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital street CDP File Number: 197463 - 1
P.O.Box 848
Mocksville NC 27028 County File Number:
Date: 10 / 1 6 / 2015
Click below to import an Image from an external location: Drawing Type:Construction Authorization
. -D APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC
Davie County Environmental Health
P.O.Bos 848/210 Hospital Street
Mocksville,NC 27028 d
'- (336)753-6780/Fax(336)753-1680
Application For: 9 Site Evaluation/Improvement Permit C Authorization To Construct(ATC) ❑Both
Type of Application: []New System CRepair to Existing System VExpansion/Modification of Existing System or Facility
•■•1MPORTAN7++'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 Ro b e r f [-j V Cl s W e-11 Contact Person
Billing Address '70'3 I=e-s'rvt i r e- 51', Home Phone 33(0-4t7 --593 L f
City/State/ZIP_$-6heloolo, K C 2-7 7,0- , Business Phone
Name on Permit/ATC if Different than Above — 5 Cxv"e —
Mailing Address City/State/Zip
PROPERTY INFORMATION 'Date House/Facility Corners Flagged
NOTE: A survey plat or site plan must accompany this application. Included:B Site Plan CPlat(to scale) S ee-Dvi cy,n n 1 Per m,�
(Permit is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name- Robe v+ at-K.4 S hct rn v 3 rcxs w e_t l Phone Number 3 aro-408--3cl34-
Owner's Address '7133 Fesvni v't 5't', City/State/Zip lk-SLAe_bVrc�N C 7-y7-y-0y0 5
i"c�-
Property Address SUR Mar.h m o n t' p r r v�. City i ve yr ee 1V C_
Lot Size -�, 27 Ate.re. Tax PIN# R ec.# G�75 32'72.1
Subdivision Name(if applicable)Wl ztrch wovvf Pt a n a on Section/Lot# V
Directions To Site:—,&(F Peoples C re-p 1c R©cid /*cLVA oce- nt
If the answer to any of the following questions is"yes",supporting documentation must be attached.
Are there any existing wastewater systems on the site? %Yes CNo
Does the site contain jurisdictional wetlands? ❑Yes ISNo
Are there any easements or right-of-ways on the site? ❑Yes)dNo
Is the site subject to approval by another public agency? []Yes$INo
Will wastewater other than domestic sewage be generated? []Yes 1allo
IF RESIDENCE FILL OUT THE BOX BELOW
#People #Bedrooms #Bathrooms 5 Garden Tub/Whirlpool❑Yes 9No
Basement:DdYes ❑No Basement Plumbing: 5dYes ❑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 CInnovative CAltemative COther
Water Supply Type:W County/City Water ❑New Well ❑Existing Well 0 Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve?0 Yes X No
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
local g an flagginging the house/facility location,proposed well location and the location of any other amenities.
Property owneerrr''s or owner'ssllegall representative signature Site Revisit Charge
Date(s):
cl^Z S Client Notification Date:
Date EHS:
Sign given [I Yes 0N Account# WLiO
Revised 11/06 Invoice#
A
DAVIE COUNTY HEALTH DEPARTMENT J, -I
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
NOTE:Issued in Compliance With Article It of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
Name r , '� `r.X�. !i / Date /'.:. 'J`f N2 G 6 4
Location
z� ► ,
Subdivision Name /���)•"1 gyp^ Lot No, i Seo-or Block No.
Lot Size <%?� House Moblle Home Business Speculation
No.Bedroonjs,- _No.Baths 'y No.in Family •P
Garbage Disposal YES ❑ NO p' Specifications for System:
Auto Dish Washer YES ID NO p
Auto Wash N. ine YES [p NO ❑ �•
Type Water Supply
'This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation If site plans or the Intended use change. re
Improvements permit by J_X
`Contact a representative of the Davie County Health Department for final inspection of this system between 8:3D-
9:30
A.M. or 1:o0-1:30 P.M. on day of completion. Telephone Number:704-634-5985.
Final Installa ion Diagram: System Installed by
1
o
i
Certificate of Completion !�� �� Date
'The signing of this certificate shall indicate that the system described above has been Installed in compliance with
the standar s set forth In the above regulation,but shall in NO way betaken as a guarantee that the system wilt function
satisfactori!I for any given period of time. _
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Po W'd:. ZM4RdjWojj4 _br,
33ba
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 .7
Landscape position
Slope%
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON H DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
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
MOW
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
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
LY9ttes
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 acceutance rate-eal/davM2 nrun ncrnc fID-4 AN
OPERATION PERMIT or ice use nv
Davie County Health Department *CDP File Number 197463-1
210 Hospital Street
P.O.Box 848 County ID Number,
Mocksville NC 27028 Evaluated For. EXPANSION
Phone: 336-753-6780 Fax:336-753-1680 Township.
Applicant: Robert Braswell Property owner. Robert and Sharon Braswell
Address: 783 Fesmire Street Address: 783 Fesmire Street
City: Asheboro City: Asheboro
State/Lip: NC 27203 StatefLip: NC 27203
Phone#: (336)408-3934 Phone#: (336)408-3934
Property Location & Site Information
r
dress/Road#: Subdivision: Marchamont Plantation Phase: Lot: 21
202 Marchmont Drive
Advance NC 27006 Directions
Structure: SINGLE FAMILY - 1-40 exit hwy 801 exit, turn right , to Peoples Creek
Rd on left after crossing RR tracks, Marchmont
of Bedrooms: 6 Plantation on left
#of People:
*Water Supply: PUBLIC
*IP Issued by. 'System Classification/Description:
TYPE III A.CONY SYSTEM>480 GPD(EXCLUDING SFO)
*CA issued by: 2140-Nations,Robed Saprolite System? 0Yes (E)No
Design Flow: 7 a 0 * GRAVITY-SERIAL Pump Required?
DisttibutionType: OYes C7No
Soil Application Rate: 0 - 2 7 5 *Pre Treatment:
Drain field
(Nitrification Field 1 7 4 6 SQ.ft• *System Type: INFILTRATOR QUICK4STANDARD
o. Drain Lines 4 Installer FrdnkTransou
Total Trench Length: 4 3 6 ft. Certification#: 2771
Trench Spacing: _ 9 ()Inches O.C.
_ * Feet O.C. *EH S: 2740-Nations,Robert
Trench Width: 3 Inches
Feet Date: 0 6 / 0 7 / 2 0 1 6
Aggregate Depth: inches _
Minimum Trench Depth: 3 6
Inches
Minimum Soil Cover. a 4 Approval Status -
Inches ` �
Maximum Trench Depth: 3 6 ® Approvetl 0 Disapproved
Inches
Maximum Sail Cover. a 4e /
Inches
CDP File Number 197463 - 1 Septic Tank County ID Ntfmber:•
Manufacturer: shoat Lat.
STB: 760
Long:
Gallons:
1000 Installer Frank transou
Certification#: 2711
Date: fa 6 / 0 7 / a 0 1 6
` *EH S: 2140-Nations,Robert
*Filter Brand: POLYLOK PL-122 With Pipe Adapter
1 6
ST Marker: 11 Yes ® No Date: 0 6 / 0 7 / a I7
ReinfarcedTank: ❑ Yes (E NO AppranialStatus
y
1 Piece Tank: ❑ Yes [� No � ®yApproved❑�Dlsapproved
Pump Tank
Manufacturer Installer.
PT: Certification#:
Gallons: *EH S:
Date: / / Date:
RiserSealed ❑ Yes ❑ No
Riser Height: ❑ Yes ❑ No (Min.6 in.) y A rovaiSfatus-
Reinforced Tank. ❑ Yes ❑ No
❑ Approved❑ Disapproveda
1 Piece Tank: ❑ Yes ❑ No
Supply Line
Pipe Size: inch diameter Installer.
Pipe Length: feet Certification#:
*Schedule: THS:
Pressure Rated ❑ Yes ❑ No Date:
Approved fittings ❑ Yes ❑ No Approval Status
❑ Approved❑ Dlsappiroved
Pump Requirement
Pump Type: Installer.
Dosing Volume: — Gal Certification#:
Draw Down: Inches *ENS.
*Chair:
Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve ElYes ElNo Apptoval,Status
PVC unions ElYes ❑ No F ❑=`A
pproved❑ Disapproved
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole ❑ Yes ❑ No
CDP File Number 197463 - 3 County ID Number:
Electric Equipment
NEMA 4X 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 *EHS:
Pump Manually Operable ❑ Yes ❑ No
*Activation Method: Date:
,Approval Status
Alarm Audible E3 Yes El No ,=Q Appro-15
ved Disapproved
Alarm Visible ❑ Yes ❑ No
2140-Nations,Robert
*Operation Permit completed by:
Authorized State Agent Date of Issue. 0 6 0 ? x 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 ef. Seq.,and all conditions of the Improvement Permit and
Construction Authorization.This property is served by a TYPE III A. sewage septic system.
Rule.1961 requires that a Type TYPE III A- septic system meet the following criteria:
Minimum System Review By The Local Health Department: WA
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency By Certified Operator:
WA
Reporting Frequency By Certified Operator.N/A
Rule .1961 requires that a Type IV and V septic systems designed fora hometbusiness 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 entitywith 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 ownerand certified operator are the same. The contract shall require specific requirements formaintenance 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 197463 - 1
Davie County Health Department CDP File Number:
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: i I
Olnch
Drawing Drawing Type: Operation Permit Scale: pelock
ON/A
I
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} � I
CONSTRUCTION For office Use Only
AUTHORIZATION "CDP File Number 197463-1
Davie County Health Department County ID Number
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 1 a / 3 0 / a 0 a 0
Applicant: Robert Braswell PropertyOwner: Robert and Sharon Braswell
Address: 783 Fesmire Street Address: 783 Fesmire Street
City: Asheboro City: Asheboro
StatefZip: NC 27203 StatefZip: NC 27203
Phone#: (336)408-3934 Phone#: (336)408-3934
Property Location & Site Information
rAddress/Road #: Subdivision: Marchamont Plantation Phase: Lot: 21
202 Marchmont Drive
Advance NC 27006 Directions
Structure: SINGLE FAMILY 1-40 exit hwy 801 exit, turn right, to Peoples Creek Rd on
left after crossing RR tracks, Marchmont Plantation on left
#of Bedrooms: 6
#of People:
*Water Supply: PUBLIC
System Specifications
Minimum Trench Depth: a 4
rDesign
ification: Provisionally Suitable Inches
Minimum Soil Cover. 1 a
ystem? OYes QNo Inches
w: 7 2 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 .2 7 5 Maximum Soil Cover: a 4 Inches
"System Classification/Description: "Distribution Type: GRAVITY-PARALLEL(eq.d-box)
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1
Gallons
"Proposed System: 25%REDUCTION 1-Piece: OYes QNo
Pump Required: OYes QNo 0 May Be Required
Nitrification Field 1 7 4 6
Sq.ft. Pump Tank: Gallons
No..Drain Lines 4 1-Piece:OYes ONo
Total Trench Length: 4 3 6 ft. GPM vs— ft. TDH
Trench Spacing: _ 9 Onches D.C.
Feet O.C. Dosing Volume: _ Gallons
Trench Width: Inches
3 - "Feet Grease Trap: Gallons
Aggregate Depth: - -
inches Pre Treatment: ONSF OTS-1 OTS-11
Septic Tank Installer Grade Level Required: 01 Oil 0111 OIV
Donn I ^f'1
CDP File Number 197463 - 1 County ID Number.
❑ Open Pump System Sheet
Repair System Required:®Yes ONo ONo, but has Available Space
rDesign
System
Trench Spacing: 9 O Inches 0. .
ification: — ©Feet O.C.
Trench Width: Inches
w: 7 2 0 _ 3 @ Feet
Soil Application Rate: 0 a 7 5 Aggregate Depth: inches
Minimum Trench Depth: a 4 Inches
*System Classification/Description:
TYPE III A.CONY SYSTEM>480 GPD(EXCLUDING SFD) Minimum Soil Cover. 1 2 Inches
*Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches
Nitrification Field a 6 1 $ Sq.ft. Maximum Soil Cover: 2 4 Inches
No. Drain Lines 6 *Distribution Type: PUMP TO GRAVITY
TotalTrerich Length: 6 5 4 ft. Pump Required: @Yes ONo OMay Be Required
PrePre-Treatment: ONSF OTS-1 OTS-II
1 - "e)
"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 bevalid for a person equal to the period of validity of the Improvement PermI%not
to exceed five years,and may be Issued at the sametime the lmproveme t Permit 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 fora permit or Construction
Authorization is found to have been Incorrect,falsified or changed,or the site is altered,me permit orConstruction Authorization shall become
Invalid,and may be suspended or revoked(.1937(8)).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: . 1 a / 3 0 / a 0 1 5
Authorized State Agent: Malfunction Log Oyes
*Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department CDP File Number: 197463 - 1
X210 Hospital Street
P.O.Box 848 County File Number.
Mocksville NC 27028 Date: 1 2 / 3 0 / 2 0 1 5
Olnch
Drawing Drawing Type: Construction Authorization Scale: . OBtock
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CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street CDP File Number: 197463 " 1
P.O.Box 848
Mocksville NC 27028 County File Number:
Date: 1 .1 / 30 / 2015
Click below to import an Image from an external location: Drawing Type:Construction Authorization
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CONSTRUCTION For Office Use Only
AUTHORIZATION *CDP File Number 197463- 1
•" Davie County Health Department
County ID Number:
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 1 0 / 1 5 a 0 0
Applicant: Robert BraswellProperty Owner: Robert and Sharon Braswell
Address: 783 Fesmire Street Address: 783 Fesmire Street
City: Asheboro City: Asheboro
State/Zip: NC 27203 State/Zip: NC 27203
Phone#: (336)408-3934 Phone#: (336)408-3934
Property Location & Site Information
Address/Road#: Subdivision: Marchamont Plantation Phase: Lot: 21
202 Marchmont Drive
Advance NC 27006 Directions
Structure: SINGLE FAMILY 1-40 exit hwy 801 exit, turn right , to Peoples Creek Rd on
left after crossing RR tracks, Marchmont Plantation on left
#of Bedrooms: 5
#of People:
*Water Supply: PUBLIC
System Specifications
Minimum Trench Depth: a 4
CSaproliteSystem?
Provisionally suitable Inches
Minimum Soil Cover: 1 �
QYes (9 No Inches
6 0 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 a 7 5 Maximum Soil Cover: a 4 Inches
*System Classification/Description: *Distribution Type: GRAVITY-SERIAL
TYPE III A.CONV SYSTEM>480 GPD(EXCLUDING SFD)
Septic Tank: 1 2 5 0
Gallons
*Proposed System: 25%REDUCTION 1-Piece: O Yes ®No
Pump Required: QYes ®No O May Be Required
Nitrification Field 8 7 3 Sq.ft. Pump Tank: Gallons
No. Drain Lines a 1-Piece: QYes ONo
Total Trench Length: a 1 8 ft GPM--vs— ft. TDH
Trench Spacing: _ Inches O.C.
9 Feet O.C. Dosing Volume: Gallons
Trench Width: _ 3 O Inches
®Feet Grease Trap: Gallons
1
Aggregate Depth:
inches Pre-Treatment: O NSF OTS-I OTS-II
Septic Tank Installer Grade Level Required: 01 011 0111 O IV
Page 1 of 3
CDP File Number 197463 - 1 County ID Number: '
❑ Open Pump System Sheet
Repair System Required:®Yes O No O No, but has Available Space
CDesign
System Trench Spacing: g O Inches O.
fication: Provisionally suitable — ®Feet O.C.
Trench Width: O Inches
w: 6 0 0 — 3 ®Feet
Soil Application Rate: 0 a Aggregate Depth:7 5 inches
.�
*System Classification/Description: Minimum Trench Depth: a 4 Inches
TYPE III A.CONY SYSTEM>480 GPD(EXCLUDING SFD) Minimum Soil Cover: 1 a Inches
*Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches
Nitrification Field 2 1 8
Sq.ft. Maximum Soil Cover: a 4 Inches
No. Drain Lines 6 *Distribution Type: PUMP TO GRAVITY
Total Trench Length: 5 4 6 ft. Pump Required: ®Yes O 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. Characters
If there isn't enough space to add an additional 1,000 gallon tank and still have fall to the existing septic lines,pump and crush existing tank.Install a 497
1,250 gallon tank,reconnect to existing septic lines,and add 218 feet of 25%reduction system.
*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. Remecr�9
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 130A-336(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(.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? O Yes O No
Applicant/Legal Reps. Signature- Date:
*Issued By: 2140-Nations,Robert Date of Issue: 1 0 / 1 6 / 22 0 1 5
Authorized State A _ Malfunction Log OYes
®Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
' CONSTRUCTION AUTHORIZATION 197463 - 1
Davie County Health Department CDP File Number:
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 1 0 / 16 / ,2015
O Inch
Ilca�inu nra �Eo ti ization Scale: O Block
Q N/A
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Page 3 of 3 Pi P2
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street CDP File Number: 197463 - 1
P.O.Box 848
Mocksville NC 27028 County File Number:
Date: .1.0./ 16 / .2 0 15
Click below to import an image from an external location: Drawing Type:Construction Authorization
Page 3 of 3
P1 P2
DAVIE COUNTY HEALTH DEPARTMENT
IMPbOVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 2=gyp
'NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
Name Date >�/� N2 6,j F,`
Location r r�;,=.�..,i .- - T /
Subdivision Name /'>>�7 ." �= Lot No. Sec-or Block No.
Lot Size f/J r House 1� Mobile Home_ Business Speculation
No. Bedrooms �� No. Baths No. in Family T"
Garbage Disposal YES ❑ NO p' Specifications for System:
Auto Dish Washer YES Q NO ❑
Auto Wash Machine YES p NO ❑
,Type Water Supply
'This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
Improvements permit by /.Z�
'Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number:704-634-5985.
/ J >
Final Installation Diagram: System Installed by
f
f�� �J S "
Certificate of Completion _Date �j�
'The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation,but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
f i DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
f `NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a
Sanitary Sewage Systems Permit"Number
Name Date N2 6064
Location eo�z�e&'2
AD 2m��2c6wa �
Subdivision Name '2-0Lot No. See-or'Block No.
Lot Size rL�'7 House �'` Mobile Home _ Business Speculation
No. Bedrooms -- ? — No. Baths No. in Family
Garbage Disposal YES ❑ NO Q' Specifications for System:
Auto Dish Washer YEST NO ❑ / � "�'L��
Auto Wash Machine YES NO ❑ /Op��� r`�
Type Water Supply — 4
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
.�• lam'
rA
1
Improvements permit byy��
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
f
Final Installation Diagram: System Installed by
`r
Certificate of Completion ZI Date
"The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
1
l
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department g
Environmental Health Section CO �VN Z
P. 0. Box 665 R`
Mockaville, NC 27028
1 . Application/Permit Requested By z _
Mailing Address y K -2- All)k1,11VCE: AIC
Home Phone ��� -73 9� Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For: C) General Evaluation U/S/Tank Installation
5. System to Serve: //House +HA,13,9's/-1_' Mobile Home 0 Business
-] Industry u Other 0 Unknown
6. If house, mobile home: Subdivision ln19 .})l40'0l - Sec. Loty
No. of People Dwelling Dimensions k
No. of Bedrooms ,^ylasement/Plumbing
No. of Bathrooms �" ` Basement/No Plumbing
Washing Machine /' i,�1 /*UI�r^C�-/ dishwasher 0 Garbage Disposal j
7. If business, industry, other:: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers
S. Type of water supply: /public 0 Private Q Community
9. Property Dimensions .CST ` X//IR7^/7L,�,,,iaT.e.�
10. Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes k-9'0
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of 5
years from date issued. Improvements Permits are subject
to revocation, if site plans or the intended use change.
Effective October 1, 1989.
This is to certify that the information provided is correct to trig_
best of my knowledge, and I understand I am responsible for all
charges incurred from this application.
Date Signature
Directions to Property :.
D A P_2 C-1 L EF 5 Crit mac:
Te i�tiD 3 3 ,4j g"q "Al—1
1��✓�c � � Cru c sS /�,�
DCHD (10-89)
• DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
SITE EVALUATION CONSENT FORM
1. Complete the form below and return to the Davie County Health Department.
2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin."
NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO
BEGIN THE REQUESTED EVALUATION.
DETACH HERE AND RETURN TO: Davie County Health Department, Environmental
Health Section, P. O. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
(office use only)
no 1. I am the owner of the above described property.
yes no 2. 1 am not the owner of the above described property, however, I certify that I
have consent from , owner to obtain a
owner's name
site evaluation by the Davie County Health Department for the purpose of
determining the suitability for a ground absorption sewage treatment and
disposal system.
no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Department to enter upon the above described property and conduct all
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
6-,Z P—?,-> e/�,j
DATE SIGNATURE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
_Owner only
ners designated representative
Anyone requesting results
Only those listed below
DATE SIGNATURE
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME DATE EVALUATED
ADDRESS PROPERTY SIZE _:Z417
PROPOSED FACIILTY -�L � LOCATION OF SITE 1�rL' Z�zCr
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position
Sloe %
HORIZON I DEPTH �� �• ��
Texture groupS S'
Consistence
Structure r
Mineralogy
HORIZON II DEPTH �/
Texture groupj
Consistence G' C C O
Structure -e;41 S'
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: ' EVALUATED BY: zz
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
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-Finn 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
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(01-901
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