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104 N Madera Dr OPERATION PERMIT or ice se nv * Davie County Health Department *CDP File Number 137232-1 210 Hospital Street Hs-190-Aa032 1? P.O. Box 848 County ID Number. Mocksville NC 27028 Evaluated For,HDR/WWC Phone:336-753.6780 Fax:336-753-1680 Township: Applicant: Southeastern Pools r erty Owner: Brian and Dawn Basham CAddress: PO Box 25271 ress: 104 N Madera Drive City: Winston-Salem y: Mocksville State2ip: NC 27114 State2ip: NC 27028 Phone#: (336)788-4740 Phone#: Property Location & Site Information Address/Road#: Subdivision: McAllister Park Phase: Lot: 32 104 N Madera Drive Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 158, right on Sain Rd. Right on Chandler, to end across street #of Bedrooms: 3 #of People: *Water Supply: PUBLIC *IP Issued by. *System Class ificatan/Description: TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140-Nations,Robert Saprolite System? QYes ONo Design Flow: 1 0 0 * GRAVITY-SERIAL Pump Required? Distribution Type: QYes QNo Soil Application Rate: 0 - a 7 5 *pre Treatment: Drain field rNoknification Field 3 6 3 SQ•It• 'System Type: INFILTRATOR QUICK 4 STANDARD rain Lines a Installer: Randy Miller Total Trench Length: 1 0 0 Certification#: 1128 Trench Spacing: _ 9 ()Inches O.C. (J)Feet O.C. *EHS: 2140-Nations.Robert Trench Width: 3 Inches — Feet Date: 0 6 / 0 6 2 0 1 4 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. 4 ,.%�pproval�Status� Inches Maximum Trench Depth: 3 6 ® Approved D Disapproved Inches Maximum Soil Cover: a 4 Inches CDP File Number 137232 - 1 Septic Tank County ID Number: 1-15.1WAa032 13 Manufacturer. shoat Lata STB: 7601 Long: + Gallons: 1000 Installer. Gandy Hitler Certification#: 128 Date: 0 1 / 4 I3 / 4 0 1 4 '--`--' 'EHS: 2140-Nations,Robert 'Filter Brand: POLYLOK PL-122 With Pipe Adapter ST Marker. ❑ Yes E No Date: 0 6 0 6 2 0 1 4 Apprpval Status Reinforced Tank: E] Yes ® No 1 Fiera Tank: ❑ Yes O No ❑ Approved❑ Disapproved Pump Tank Manufacturer Installer. PT: Certification#: Gallons: 'EHS: Date: Date: RiserSealed ❑ Yes ❑ No RiserHeght: [:1 Yes ❑ No (Min.6 in.) A rovalStatus ❑...Yes ❑ N o pp Reinforced Tank: ❑ Approved❑ Disapproved 1 Piece Tank: ❑ Yes ❑ No Supply Line Pipe Size: inch diameter Installer Pipe Length: feet Certification#: "Schedule: 'EHS: Pressure Rated ❑ Yes ❑ NO Date: Approved fittings E] Yes ❑ NO , Approval Status ❑ Approved❑ Disapprovetl Pump Requirement Pump Type: Installer. Dosing Volume: — Gal Certification#: Draw Down: Inches `EHS: 'Chain: Date: Valves Accessible ❑ Yes ❑ NO Flow Adjustment Valve ❑ Yes ❑ No Check-valve ❑ Yes ❑ No Approval Status PVC unions E) Yes El No ❑ Approved❑ Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole El Yes 0 No CDP File Number 137232 - 1 County ID Number: H54MAM2 Y Electric Equipment NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer. Box 12 inches Above Grade ❑ Yes ❑ No Box Adj.To Pump Tank Certification#: ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ NO 'EHS: Pump Manually Operable ❑ Yes ❑ No *Activation Method: Date: <ApproyalStatus , Alam,Audible ❑ Yes ❑ No ❑ Approved❑ [71sapproved . Alarm Visible ❑ ��7es ��Wo „. ,11-11 2140•Nacons,Robert 'Operation Permit completed by: Authorized State Agent: Date of Issue: 0 6 / 0 6 / 2 0 1 4 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 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: WA 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 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 ownerand 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 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. O Hand Drawing OlmportDrawing **Site Plan/Drawing attached.** OPERATION PERMIT 1372,32 - 1 Davie County Health Department CDP File Number: , 210 Hospital Street 1-15.190-AO-032 P.O.Box 848 County File Number: Mocksville NC 27028 Date: J / OI ch Drawing Drawing Type: Operation Permit Scale: ON lock ft; I l I II l I I I I V u s- _. CA Sf I , b ---------- I Y F F ` - CONSTRUCTION For office use only AUTHORIZATION *CDP File Number 1372312-2 00 Davie County Health Department County ID Number- HS-190-AO-032 , 210 Hospital Street Evaluated For. ,NEW P.O. Box 848 Townshi Mocksville NC 27028 PERMIT VALID UNTIL: Phone:336-753-6780 Fax:336-753-1680 0 5 / 1 3 / 2 0 1 9 Applicant: Brian Basham Property Owner: Brian Basham Address: 104 North Madera Drive Address: 104 North Madera Drive City: Mocksville City: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 Phone#: Phone#: Property Location & Site Information Address/Road#: Subdivision: ►V 10II'54,0(' (,fir V. Phase: Lot: 32 104 N Madera Drive Mocksville NC 27028 Directions Structure: OTHER Hwy 158, right on Sain Rd. Right on Chandler,to end across street #of Bedrooms: #of People: *Water Supply: PUBLIC System Specifications Minimum Trench Depth: a 4 Inches (Design e Classification: Provisionally suitable Minimum Soil Cover: 1 a roliteSystem? OYes (gNo Inches Flow: 1 0 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: a 7 5 Maximum Soil Cover: 2 4 Inches *System Classification/Description: *Distribution Type: GRAVITY-PARALLEL(eq.d-box) TYPE 11 A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons *Proposed System: 25%REDUCTION 1-Piece: O Yes ®No Pump Required: OYes ®No O May Be Required Nitrification Field 3 6 3 Sq.ft. Pump Tank: Gallons No. Drain Lines a 1-Piece: OYes ONo Total Trench Length: 9 0 ft GPM--vs-- ft. TDH Trench Spacing: Inches O.C. — 9 O 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 O 111 01V Page 1 of 3 CDP File Number 137232 - 2 County ID Number: H5-190-Ao-032 ❑ Open Pump System Sheet Repair System Required:0 Yes ONO ONO, but has Available Space rDesignFlow: System Trench Spacing: 9 O Inches O.C. fication: Provisionally Suitable — ®Feet O.C. Trench Width: O Inches 1 0 0 1 - 3 ®Feet Soil Application Rate: 0 a Aggregate Depth:7 5 inches .� *System Classification/Description: Minimum Trench Depth: 02 4 Inches TYPE 11 A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Minimum Soil Cover: 1 a LESS) Inches *Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Nitrification Field 3 6 3 Sq.ft. Maximum Soil Cover: a 4 Inches No.Drain Lines oZ *Distribution Type: GRAVITY-PARALLEL(eq.d-box) Total Trench Length: 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. 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 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(.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? O Yes O No Applicant/Legal Reps.Signature: Date: *Issued By: 2140-Nations,Robert Date of Issue: 0 5 / 1 3 / .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 137232 - 2 Davie County Health Department CDP File Number: 210 Hospital Street H5-190-AO-032 P.O.sox 848 County File Number: Mocksville NC 27028 Date: 05 / 13 / .1014 O Inch Drawing Drawing Type: Construction Authorization Scale: . O Block O N/A S Vw L ti a s . 5 o � Page 3 of 3 P1 P2 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: 137232 -2 P.O.Box 848 H5-190-AO-032 Mocksville NC 27028 County File Number: Date: .0.5./ 13 V2 0 14 Click below to import an image from an external location: Drawing Type: Construction Authorization Page 3 of 3 P1 P2 APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC Davie County Environmental Health RECEIVED P.O.Box 848/210 Hospital Street Mocksville,NC 27028 Date: y'�� (336)753-6780/Fax(336)753-1680 Application For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Type of Application:XNew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name brar) AJQ Contact Person �TI(111 Q Q11, Address le --Alb Home Phone rVa- City/stateg/ZIP h?oC Sd,11A7 Xl e Z7oze Business Phone Email Com Name on Permit/ TC 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 v lid for 60 the ith site plan,no expiration with complete plat.) Owner's Name }�1( Phone Num er -7D�-2�)- Owner's Address /o City/State/Zip MOC, V/ Property Address a- City Lot Size ,�, GLCr�S Tax PIN# Subdivision Name(if licable) '-A h Y Se tion/Lot# Direct To Sit y Q, Specify Problem Occurring: IF RESIDENCE FILL OUT THE BOX BELOW FP eople #Bedrooms #Bathrooms Garden Tub/Whirlpool ❑Yes ❑No sement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑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? 17 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 to ting and fl a ng staking the house/facility location,proposed well:location and the location of any other:amenities. Site Revisit Charge operty owner's or owner's legal representative signature s<' )� Date(s): �( -Client Notification Date:y Date EHS: � Sign given ❑Yes ❑No Account#. Revised 11/06 Invoice# �27+ t1JJ +jf J 22332 - - a 1 AICALLISTER 1 ml / PARK"'� �+b,, CO My G �Q 4r0 a 147 n 17, cp1 .27.3 _ __2.41 ' �• � � �,. tj+t o NI data Is provided as Is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the Implied t\\' warrandes of merchantability orfftness fora particular use.M 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:Apr 23r 2014 of the use or Inability to use the GIS data provided by this webslto. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section , Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: Tax PIN/EH#: -> 13 Billed To: Subdivision Info: ! J Reference Name: r�� Location/Address: i Proposed Facility: Property Size: Date Evaluated: 4 'Water Supply: On-Site Well Community Public i Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe% HORIZON I DEPTH Texture group Consistence . Structure Mineralogy HORIZON II DEPTH Texture group Consistence i Structure i Mineralogy HORIZON III DEPTH Texture group Consistence Structure i Mineralogy HORIZON IV DEPTH j Texture group Consistence Structure Mineralogy' SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: i 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 I 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 !CONSI4TENC . . Moist VFR-Very friable FR-Friable FI-Firm VFI-Very firm Ek-Extremely fret e' t NS-Non sticky SS -Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic i Structure i 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 Horizon depth-In inches I 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) 1 LTAR-Long-Eerm accentance rate-val/davM2 nvric CD__X%