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189 Murphy RdOPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753.6780 Fax: 336-753-1680 Applicant: Robin Barnhardt Foster Address. 1135 Main Church Rd CRY: Mocksville State/Zip: NC 27028 Phone #: Pro Address/Road #: --GaagNmne1189 Murphy Rd Mocksville NC 27028 Structure: MOBILE HOME # of Bedrooms. # of People: *Water Supply: NtA *CDA File Number 202028-1 County ID Number: Evaluated For. REPAIR Township: !Property owner: Robin Barnhardt Foster Address: 1135 Main Church Rd City: Mocksville State/Zip: NC 27028 Phone #: lerty Location & Site information Subdivision: Phase: Lot: Directions Hwy 601 North left on Candi Lane on the right toward end. *IP Issued by. *System Classification/Description: TYPE 11 A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140 - Nations, Robert Saprolite System? OYes Q No Design Flow: 3 6 0 GRAVITY -SERIAL Pump Required? Distribution Type: OYes (DNo Soil Application Rate: 0 - a 7 5 'Pre -Treatment: Drain field Nitrification Field No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: Aggregate Depth: 1 3 0 9 Sq. ft. 3 3 a 7 ft• Inches O.C. Feet O.C. 3 ()Inches Feet inches Minimum Trench Depth: 3 6 Minimum Soil Cover, a 4 Maximum Trench Depth: 3 6 Maximum Soil Cover: a 4 Inches *System Type: INFILTRATOR QUICK 4 STANDARD Installer: Jamie Barnes Certification #: 1018 *EH S: 2140 -Nations. Robert Date: 0 8/ 1 5/ 2 0 1 6 Inches Approval Status Inches a Approved 0 Disapproved Inches CDP File Number 202028 - 1 r !Gallons: turer. STB: Date: *Filter Brand: ST Marker: ❑ Yes ❑ No nforced Tank: ❑ Yes ❑ No 1 Piece Tank: ❑ Yes ❑ NO Manufacturer. PT: Gallons: County ID Number: septic 1 dt1K Lat. Long: Installer: Certification 4: *EHS: Date: Approval Status ❑ Approved ❑ Disapproved Pump Tank Date: / / RiserSealed ❑ Yes ❑ No RiserHeight: ❑ Yes ❑ NO (Min.6 in.) Reinforced Tank: ❑ Yes ❑ No ,\-.,,Piece Tank: ❑ Yes ❑ No Pipe Size: inch diameter Pipe Length: feet *Schedule: Pressure Rated ❑ Yes ❑ No approved fittings ❑ Yes ❑ No Installer Certification 9: *EHS: Date: Approval Status ❑ Approved ❑ Disapproved Supply !wine Installer: Certification K: *EHS: Date: Approval Status ❑ Approved ❑ Disapproved J % Pump Type: Installer: Dosing Volume: - Gal Certification #: Draw Down: Inches *EHS: *Chau: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check -valve ❑ Yes ❑ No Approval Status, PVC unions ❑ Yes ❑ No ❑ Approved ❑ Disapproved Vent Hole ❑ Yes ❑ No Anti -siphon Hole 0 Yes ❑ No CDP File Number 202028 -1 Electric Eauloment County ID Number: 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 *ENS' Pump Manually Operable ❑ Yes ❑ No / *Activation Method: Date: Alarm Audible El Yes ElNo Approval Status ❑ Approved Disapproved Alarm Visible ❑ Yes ❑ No 2140 - Nations. Robert *Operation Permit completed by: /I Authorized State Agent: : Q ""� Date of Issue: 0 8/ 1 5/ 2 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 et. Seq., and all conditions of the Improvement Permit and Construction Authorization. This property is served by TYPE 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: WA 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 homelbusiness owner must maintain a valid contract with a public management entitywkh a certified operatoror a private certified operator forthe life of the septic system. Rule .1961 requires thatType VI septic systems designed fora home/business owner must maintain a valid contract with a public management entity with a certified operator forthe 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 OlmportDrawing **Site Plan/Drawing attached.** OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC Drawing Drawing Type: Operation Permit CDP File Number: 202028 -1 County File Number: 27028 Date: 0 Inch Scale: 0131ock ON/A T A 'CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street •� �,• P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Robin Barnhardt Foster Address: 1135 Main Church Rd City: Mocksville State/Zip: NC 27028 Phone M Address/Road M Subdivision: Candi Lane/189 Murphy Rd Mocksville NC 27028 Structure: MOBILE HOME # of Bedrooms: # of People: *Water Supply: NSA � For Office Use Only *CDP File Number 202028 - 1 County ID Number: Evaluated For: REPAIR Township: PERMIT VALID UNTIL: 0 4/ 0 5/ a 0 a 1 Property Owner: Robin Barnhardt Foster Address: 1135 Main Church Rd City: Mocksville State/Zip: NC 27028 Phone #: Information Phase: Lot: Directions Hwy 601 North left on Candi Lane on the right toward end. m SDecificati Page 1 of 3 Minimum Trench Depth: a 4 Inches \Site Classification: Provisionally suitable Saprolite System? O Yes (g No Minimum Soil Cover: .1 a Inches Design Flow: 3 6 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 II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: Gallons *Proposed System: 25% REDUCTION 1 -Piece: O Yes O No Pump Required: O Yes O No 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 a 6 GPM --vs-- ft. TDH ft. Trench Spacing: — 9 O Inches O.C. ® Feet O.C. Dosing Volume: Gallons Trench Width: 3 Inches Feet — Grease Trap: Gallons Aggregate Depth: inches Pre -Treatment: O NSF OTS -1 OTS -11 / Septic Tank Installer Grade Level Required: 01011 OIII ON Page 1 of 3 CDP File Number 202028 - 1 *Site Classification: Design Flow: Soil Application Rate: *System Classification/Description: County ID Number: ' V T e5 V IVU v IVU, UUL l Ids NVdIIdUIC o *Proposed System: Nitrification Field Sq. ft. No. Drain Lines Total Trench Length: ft. ❑ Open Pump System Sheet Trench Spacing:_ O Inches O. ---8Feet O.C. Trench Width: 8 Inches Feet Aggregate Depth: inches Minimum Trench Depth: Inches Minimum Soil Cover: Inches Maximum Trench Depth: Inches Maximum Soil Cover: Inches *Distribution Type: Pump Required: Oyes 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. Rm� 9 750 *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. Rama9 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: 0 4 / 0 5 / .1 0 1 6 Authorized State Malfunction Log OYes ® Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2of3 • _ � � CONSTRUCTION AUTHORIZATION 202028 - 1 ' ' Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville Nc 2�o2a Date: 0 4 / 0 5 / a 0 1 6 �Inch Drawing Drawing Type: Construction Authorization ale: , , O B�ock = . ,ft. 0 N/A _ _ __. : _ __. _ ___, __ __.. _. � _ ,.. _._ , __. ;_ _ _ . , i , _ .. , _ ....., _ ,_... _...__ , ; : , : l _. , . _....... _..... . ,........ _ , _. , , _ , _. , � , , � _ _. _ __. � � � , :..._. � __ _ � I ' � _ _____ _ ; _ ,_..... e� , .. _ ra , __.... � � , �� � _ , _ ,_ ? � _ _ _ r-... _..._ . � � � .. . ; � . .... _ _ , _. , ,.... 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Box 848 Mocksville NC 27028 County File Number: Date: A4./ . 0.5 . / ...0.1.6. Click below to import an image from an external location: Drawing Type: Construction Authorization �A �JI I f� r j Page 3 of 3 P1 P2 Davie COUNTY 210 Hospital Street r P.O. Box 848 Mocksville NC 27028 TEL: 336-753-6780 FAX:336-753-1680 Request ID: 64125 REQUEST FOR SERVICE/COMPLAINT INVESTIGATION REPORT REQUEST DATE: 03/14/2016 TAKEN BY: SECTION: N/A TYPE: PROPERTY NUMBER: 202028 ASSIGNED TO: Nations, Robert ESTABLISHMENT NUMBER: PERSON OR PREMISES TO SEE: OWNER: Robin Barnhardt Foster Robin Barnhardt Foster 1135 Main Church Rd Candi Lane/189 Murphy Rd Mocksville , 27028 Mocksville NC, 27028 REQUESTED BY: Thomas Foster HOME: WORK: Cell: Additional Information: CONDITION REPORTED: Landlord said problem with septic COMMENTS: RECORD OF INVESTIGATION Next Inspection Date: Status of Complaint: OPEN Resolved Date: Complaintant Contacted: NO j Davie County, NC GoW X Davie County Document X Appraisal Card x maps1roktech.net/davie -gomaps/index.html# I W ............. C) C) (b -1-819 -j I Number: 03030A0063 ,umber: 3820342633 ,nt Number: 27074750 Owner #1: FOSTER ROPIN EARNHARDT Owner *2: N - ------------ PB03-PG116 155' 10 rl 01hi 0592 (N Lj 11 12 40M 109, ft Latitude: 33- 57'1.59- Longitude: -80- 36'37.56' d ORO)g 185 kk 3 Address 1- Address 2; I89 MURPHY ROAD 1841 i MOCKSVILLE -3704 1 NC de: 27028-0000 0 bescrjptiom 0.562 AC OFF HWY 601 C)0.55 0780 o AAl 179 N - ------------ PB03-PG116 155' 10 rl 01hi 0592 (N Lj 11 12 40M 109, ft Latitude: 33- 57'1.59- Longitude: -80- 36'37.56' d ORO)g (.\f \ All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the implied � W 'r, warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out printed :Au 19 2015 of the use or inability to use the GIS data provided by this website. 9