339 Michaels Rd OPERATION PERMIT F-CDP
ice se ny
~ Davie County Health Department Number 137392-1
210 Hospital Street
P.O.Box 848 umber.
Mocksville NC 27028 Evaluated For REPAIR
Phone:336-753-6780 Fax:336.753.1680 Township'
Applicant: Julie Pinnix Property Owner. Julie Pinnix
Address: 339 Michaels Road Address: 339 Michaels Road
City: Mocksville City: Mocksville
State/Zip: NC 27028 State2ip: NC 27028
Phone#: (336)284.5037 Phone#: (336)284-5037
Property Location & Site Information
r
ad#: Subdivision: 9Rllie �I�r�S Phase: Lot: a-1ael's Road
le NC 27028 Directions
Hwy 601 South to Hwy 801 turn right, Michaels Rd
Structure: SINGLE FAMILY on Right.
#of Bedrooms: 3
#of People:
*Water Supply: PUBLIC
*IP Issued by.
*System Classification/Description:
TYPE It A CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by: 2140-Nations.Robert
Saprolite System? QYes &No
Design Flow: a 6 0 *Distribution Type: GRAVITY-SERIAL Pump Required?
QYes ( No
Soil Application Rate: 0 - a 7 5 *Pre Treatment:
Drain field
(Nitrification Field 1 3 09Sq•ft• *System Type: INFILTRATOROUICK4STANDARD
o. Drain Lines 5 Installer: Sherman Dunn
Total Trench Length: 3 a 7 ft. Certification#: 2702
Trench Spacing: _ 9 Inches O.C.
()Inches
O.C. *EHS: 2140-NaGons.Robert
Trench Width: — 3 Oinches
Date: 0 5 / a 1 / a 0 1 4
Aggregate Depth: inches
Minimum Trench Depth: 3 6 Inches
Minimum Soil Cover. a 4 Approval Status
Inches s
Maximum Trench Depth: 3 6 Inches ® Approved CI;Disapproved
Maximum Soil Cover. a 4
Inches
CDP File Number 137392- 1 Septic Tank County ID Number:
'
Manufacturer. Lat.
STB: Long:
Gallons: Installer.
Date: Certification#:
'EHS:
'Filter Brand:
Date:
ST Marker. ❑ Yes 11No
Reinforced Tank: E) Yes C1 No Approval5tatus
Piece Tank: ❑ Yes ❑ No ❑_Approved❑ Usapprovea'
Pump Tank
Manufacturer Installer.
PT: Certification#:
Gallons: THS:
Date: Date:
RiserSealed ❑ Yes ❑ No
RiserHeght: ❑ Yes ❑ No (Min.6 in.)
— Approvaltatus
Reinforced Tank: ❑ Yes ❑ NO ..
❑ Approved❑ Disapproved
1 Piece Tank: p Yes ❑ No
_ Supply Line
7PipoeSize: inch diameter Installer.PfeetCertification 9Schedule:
THS:
Pressure Rated ❑ Yes ❑ No Date: _
Approved fittings ❑ Yes ❑ No �71 Approval Status
W-' Approv21
ed❑ Dlsapprovetl
Pump e u e
Pump Type: Installer.
Dosing Volume: — Gal Certification#:
Draw Down: Inches 'EHS:
'Chair:
Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve El Yes ❑ No ApprairalStatus==
PVC unions El Yes ❑ No ------j ❑ ,Approved L7 Disapproved
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole El Yes 0 NO
CDP File Number 137392 - 1 County ID Number:
Electric Equipment
NEMA4XBoxorEquivalent ❑ 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 13 Yes _ ❑ No p(Approved❑ Dlsappraved
Alarm Visible ❑ Yes ❑ No
2140•Nations.Robert
*Operation Permit completed by
" Authorized State Agent: Date of Issue: 0 5 / -1 1 / 2 0 1 4
77
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 n?E 11 A. sewage septic system.
Rule .1961 requires that a Type TYPE 11 A septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: N/A
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency By Certified 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 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 ownerand systems operator,provisions that the contract shall be in effect for as tong 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
Davie County Health Department CDP File Number: 137,392 - 1
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: / 1
Q Inch
Drawing Drawing Type: Operation Permit - Scale: ON A k
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CONSTRUCTION For office use only;
• AUTHORIZATION *CDP File Number 137392 1
Davie County Health Department County lD Number
210 Hospital Street Evaluated For REPAIR
P.O. Box 848 Township
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 0 4 / a 9 .1 0 1 9
7Address:
: Julie Pinnix Property Owner: Julie Pinnix
339 Michaels Road Address: 339 Michaels Road
Mocksville City: Mocksville
State/Zip: NC 27028 State/Zip: NC 27028
Phone#: �(336) 84-5037 Phone#: (336)284-5037
Property Location & Site Information
Address/Road M Subdivision: Phase: Lot:
339 Michael's Road
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 601 South to Hwy 801 turn right, Michaels Rd on
Right.
#of Bedrooms: 3
#of People:
*Water Supply: PUBLIC
System Specifications
Minimum Trench Depth:
(Design
te Classification: Provisionally suitable Inches
prolite System? OYes (9 No Minimum Soil Cover: Inches
Flow: 3 6 0 Maximum Trench Depth: Inches
Soil Application Rate: 0 .2 7 5 Maximum Soil Cover: Inches
*System Classification/Description: *Distribution Type:
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
Gallons
*Proposed System: 25%REDUCTION 1-Piece: OYes ONO
Pump Required: OYes ONO O May Be Required
Nitrification Field 1 3 0 9 Sq.ft. Pump Tank: Gallons
No. Drain Lines 3 1-Piece: OYes ONO
Total Trench Length: 3 .2 7 ft GPM—vs-- ft. TDH
Trench Spacing: Inches O.C.
- 9 $Feet O.C. Dosing Volume: _ Gallons
Trench Width: 3 Inches
Feet Grease Trap: Gallons
Aggregate Depth: inches Pre-Treatment: O NSF OTS-1 OTS-II
Septic Tank Installer Grade Level Required: 01 O II 0111 ON
Page 1 of 3
CDP File Number*13739L2 1 County ID Number:
❑ Open Pump System Sheet
Repair System Required:0 Yes ONO O No, but has Available Space
Repair System
Trench Spacing: Q Inches O.C.
"Site Classification: — O Feet O.C.
Trench Width: Q Inches
Design Flow: — 8 Feet
Aggregate Depth:
Soil Application Rate: inches
.� Minimum Trench Depth:
*System Classification/Description: Inches
Minimum Soil Cover:
Inches
Maximum Trench Depth:
*Proposed System: Inches
Maximum Soil Cover:
Nitrification Field Inches
Sq.ft.
No. Drain Lines *Distribution Type:
Total Trench Length: ft Pump Required: QYes QNo QMay Be Required
Pre-Treatment: O NSF OTS-I OTS-II
*Site Modifications
adm
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. R
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. R„aim`'g
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(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 O No
Applicant/Legal Reps.Signature: Date:
*Issued By: 2140-Nations,Robert Date of Issue: 0 4 / 2 9 / 2 0 1 4
Authorized State Agent: Malfunction Log OYes
®Hand Drawing O Import Drawing .
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION 137392 - 1
Davie County Health Department CDP File Number:
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 04 / a9 / .2014
O Inch
Drawing Drawing Type: Construction Authorization Scaler , 00 NSA Block = , ,ft.
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Page 3 of 3
P1 P2
' CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital street CDP File Number: 137392 - 1
P.O.Box 848
Mocksville NC 27028 County File Number:
Date: .H.4./.a.9 .2 0 1.4.
Click below to import an image from an external location: Drawing Type: Construction Authorization
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Page 3 of 3
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DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) 33�_ J
PHONE NUMBER
ADDRESS J'")9 1 I I i'( ha.e l SUBDIVISION NAME
`` LOT #
DIRECTIONS TO SITE COMC (iak)n (A(5) , l Qsl- 'CA nj� P). ) bdore
Gr rSw - Co m ffi on oac',h 59
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS 3 NUMBER PEOPLE SERVEp
TYPE WATE�R,I SUPPLY SPECIFY PROBLEM OCCURRING , e_Ab-Q f✓O
DA4 REQUESTEDI INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge,and that I understand 1 am responsible for all charges Incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1193 37�/]�
# Page 1 of 1
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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PERMIT - -
**NOTE#* This improvement permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater
system. _AN AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S. Chapter 13OA, Wastewater Systems, Section .1980 Sewage Treatment and Disposal Systems)
NAME PROPERTY ADDRESS Al. — DATE E
LOCATION
SUBDIVISION NAME --Y��i`� /YC LOT NUMBER / SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE D./7, 8 BEDROOMS _-�/ # BATHS 1 OCCUPANTS GARBAGE DISPOSAL: Yes/No
ar
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPI-E/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE Y?cam TYPE WATER SUPPLY �� DESIGN WASTEWATER FLOW (GPD) FEW SITE _J/ REPAIR SITE
/P// 3 061
SYSTEM SPECIFICATIONS: TANK SIZE /fbD 6A1.. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTHLINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
THIS PERMIT IS SUBJECT TO (EVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. -
t
- p
IMPROVEMENT PERMIT BY
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN
8:38-9:38 A.M. OR 1:80-1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8768.
OPERATION PERMIT SYSTEM INSTALLED BY
NQ ►tv
�70
AUTHORIZATION NO. O 1'� OPERATION PERMIT BY \ , DATE o Q-9�
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH
ARTICLE 11 OF G.S. CHAPTER 13OA, SECTION .1908 "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.
DCHD 10/95
VIX
Davie County Health Department"
ENVIRONMENTAL HEALTH SECTION
v
P.O..Box 665 . .
Mocksvi-lle;;N.C. 27028
AUTHORIZATION FOR WASTEWATER.;SYSTEM CONSTRUCTION
(Issued in compliance with Article 11 of ;
G.S. Chapter 130A, Wastewater Systems)
t *This Authorization For Wastewater System Construction must be issued''by the' Davie County Environmental Health Section prior to
issuance of any Building Permits. This Form/Authorization Number should be pr ented to the Davie ounty Building Inspections
Office when applying for Building Permits.+* / / / ,('�
I
I""(a (S AUTHORIZATION NLIVBER
NAME DATE �-cV 2 . 9/ d° 0410
NAME ON IMPROVEMENT PERMIT (If different than above) `
SITE LOCATION
COMMENTS/CDNDITIDNS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
s
***NOTICE*** THIS AUTHORIZATION STEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
ENVIRONMENTAL HEALTH SPECIALIST
.DATE
DCHD 10/95
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI
Davie County Health Department D
Environmental Health Section
P. O. Box 665 JUN 1 9 1996
Mocksville, NC 27028
1. Application/Permit Requested By
Mailing Address p��, ��3� Home Phone
Business Phone
2. Name on Permit if Different than Above
3. Application for: ❑General Evaluation Septic Tank Installation Permit
4. System to Serve: ❑ House R Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry nn ee ❑ Other ❑ Unknown
5. If house, mobile home:Subdivision .0 -A a."n) Section Lot #
❑ Basement/Plumbing
No.of People ❑ Basement/No Plumbing
No. of Bedrooms ,, ❑ Washing Machine
j
No. of Bathrooms ,/ ❑ Dishwasher
Dwelling Dimensions Q(,,1�/a- 1�s� ❑ Garbage Disposal
6. If business, industry, place of public assembly, 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 Water Usage Figures
7. Type of water supply: Public ❑ Private ❑ Community
8. Property Dimensions C)ID Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ff No
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.
-------------
Directions to Property:
P1,10PERTY INFORAJATION REQUIRED:
Tax Office PIN # D
Road Name y"Y1,'n j✓� �;,
Box ,f (if available)
City06JrAC-)
r
This is to certify that the information provided is correct to e b st of my knowl e, I understand I am responsible for all charges
incurred from this application.
1411296, .
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
Fand
ECK ONE: ❑ 1. 1 OWN the property. e. I DO NO-(OWN the property.
ked Box#2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
ve consent to the authorized representativeof the De�vvie Coun�teYr Health Dep rtment to enter upon above described
cated in Davie County and owned by t�YY Q t-M �Y'lYr)K� �.
all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
al system..,/i$��o
DATE SIGNATURE
DCHD(1 183)
is
�`� '• y 'APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI M 10
Davie Count Health Department
Y p JUL 2 1 199.5-
P.
995-
/� Environmental Health Section
W t P. O. Box 665
1 I
Mocksville, NC 27028 EMZH
1. Application/Permit Requested By ( oti a 'alrY'7 s4e e— Zoe. gl Nrtkice_
/ v
Mailing Address �+' �tll� '/ � - !� / Home Phone to �g 33
� 0 'ks �; � Business Phone k T ;ZJs�
2. Name on Permit if Different than Above ,
3. Application for. ��// General Evaluation ❑Septic Tank Installation Permit
4. System to Serve: ®'House ❑ Mobile Home ❑ Place of Public Assembly
J..
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home:Subdivision Section Lot#
❑ Basement/Plumbing
No. of People • _ ❑ Basement/No Plumbing
No. of Bedrooms ❑ Washing Machine
No. of Bathrooms A-1. ❑ Dishwasher
' ,lDO Dwelling Dimensions
❑ .Garbage Disposal
6. If business, industry, place of public assembly, 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 Water Usage Figures
7. Type of water supply: ublic ❑ Private ❑ Community
8. Property Dimensions fid O �� V ,5(90 Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes "o
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.
Directions to Property: /—
l /
,�•7s
� l
This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurred m this a plication
� ��
DATE SIGNATURE '
mn
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED 9ROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box#2,the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representativ of the Dpie Conty Healthartment to enter upon above described
property located in Davie County and owned by s gm, edv;iP 271f .
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE IGNATURE
DCHD(1193)
DAVIE COUNTY HEALTH DEPARTMENT J-17
Environmental Health Section
Soil/Site Evaluation
NAME DATE EVALUATED l/_2��
ADDRESS ' J PROPERTY SIZE
PROPOSED FACIILTY L✓r LOCATION OF SITE
Water Supply: On-Site Well _ Community Public
Evaluation By: Auger Boring Pit 6/ Cut
FACTORS 1 1 2 3 4
Landscape position
Slope %
HORIZON I DEPTH
Texturegroup
Consistence
Structure
Mineralogy
HORIZON II DEPTH F ti
Texture group
Consistence �
Structure A� 0/1-
Mineralogy
/GMineralo .�
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: '/ytI f�
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 :lay loam- SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
CONSISTENCE
Moist
VFR-Vc.-y friable FR-Friable FI-Finn VFI-Very firm EFI-Extremely fine
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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