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224 No Creek Rd OPERATION PERMIT EEvaluatedFor.NEW e n v fes. Davie County Health Department r 124057-1 210 Hospital Street ! 5768402849 P.O.Box 848 .Mocksville NC 27028 WPhone:336-753-6780 Fax:336-753-1680 Applicant: Scott Smith rAddrerss-:.O' ey ner: Amanda Shoffner/Jodey Barber Address: 113 Fostall Drive 607 Auril Hurt Road, Lot#15 CRY: Mocksville City: Lexington StatefLip: NC 27028 !State/Zip: NC 27295 Phone#: (336)782-1647 Phone#: Property Location & Site Information ,r,s/Road#: Subdivision: Phase: Lot: Creek Road ksville NC 27027 Directions Hwy;64 East, Left on No Creek Rd. on Right just past Structure:- SINGLE FAMILY Aubrey Merrell Rd. #of Bedrooms: 3 #of People: *Water Supply: PUBLIC *IP Issued by. *System Classification/Description: TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: SaproliteSystem? OYes @No Design Flow: 3 6 0 GRAVITY-SERIAL Pump Required? 'Distribution QYes (E)No Soil Application Rate: 0 3 *Pre Treatment: Drain field N ilrification Field 1 a 0 0 Sq.ft. *System Type: INFILTRATOR QUICK 4 STANDARD No. Drain Lines 3 Installer: William Rueben Clayton Total Trench Length: 3 0 0 Certification#: 2694 Trench Spacing: — 9 Inches O.C. • Feet O.C. *EH S: 2140-Nations,Robert Trench Width: 3 Olnches feet Date: 1 a / 0 3 / a 0 1 4 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4 Inches ApprovalStatus` Maximum Trench Depth: 3 6 ® "Approved Disapproved Inches Maximum Soil Cover, a 4 Inches CDP File Number 124057- 1 County ID Number. 5768402849 Septic Tank F Manufacturer. Shoat Let. STB: 760 Long: Gallons: 1000 Installer: William Rueben Clayton Certification#: 2694 Date: 0 t3 / 1 9 / x 6 1 4 'EH S: 2140-Nations,Robert "Filter Brand: POLYLOKPL-122 With Pipe Adapter ST Marker: 11 Yes 9 NO Date: l a / 0 3 x 0 1 4 / Approval Reinforced Tank: ❑ Yes ® No Status Piece Tank: ❑ Yes ® No ® Approved❑ Dlsapprovect� ...................o.,/ Pump Tank Manufacturer. Installer PT: Certification#: Gallons: 'EH S: Date: / / Date: RiserSealed ❑ Yes ❑ No RiserHeght: ❑ Yes ❑ No (Min.6 in.) Approval Status Reinforced Tank: ❑ Yes ❑ No ❑ gpprayed❑=Disapproved 1 Piece Tank: ❑ Yes ❑ NO „_ 1ky Supply Line Pipe Size: inch diameter Installer: Pipe Length: feet Certification#: "Schedule: "`EHS: Pressure Rated ❑ Yes ❑ No Date: Approved fittings ❑ Yes ❑ NOApproval Status24, f ❑ Approved❑ Dlsapproveo Pump Requirement Pump Type: Installer. Dosing Volume: — Gal Certification#: Draw Down: Inches *EHS: "Chan: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check-valve El Yes ❑ NoAppranraIStaI' PVC unions ❑ Yes ❑ No ❑ ApprovedElDisapprovetl Vent Hole ❑ Yes ❑ No Anti-siphon Hole El Yes 0 No CDP File Number 124057 - 1 County ID Number: 5768402849 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 S Alarm Audible ❑ Yes ❑ No 6iAppr6ii6do-,,Disapproved, Alarm Visible ❑ Yes ❑ No 2140-Nations.Robert *Operation Permit completed by: Authorized State nt: Date of Issue: 1 2 / 0 3 / 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 repE It A. sewage septic system. Rule.1961 requires that a Type TYPE II X septic system meet the following criteria: Minimum System Review ByThe Local Health Department: NIA Management Entity: OWNER M nimum System Inspection/Maintenance Frequency By Certified Operator. N/A 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 entitywrlh 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 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 124057 - 1 Davie County Health Department CDP File N umber: 210 Hospital Street 5768402849 P.O.Box 848 County File Number: Mocksvilte NC 27028 Date Olnch Drawing Drawing Type: Operation Permit Scale: . O = ft. ON/A�a F� •b CONSTRUCTION For Office'useoniy AUTHORIZATION *CDP File Number 124057-1 Davie County Health Department County ID Number: 5761402849 r.? 210 Hospital Street Evaluated For. NEVA P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax:336-753-1680 1 1 / 2 1 2 0 1 8 Applicant: Scott Smith r roperty Owner: Amanda Shoffner/Jodey Barber Address: 113 Fostall Drive ddress: 607 Auril Hurt Road, Lot#15 CRY: Mocksville AY: Lexington State2ip:, NC 27028 State/Zip: NC 27295 Phone#: (336)782-1647 Phone#: Property Location & Site Information Address/Road #: Subdivision: Phase: Lot: No Creek Road Mocksville NC 27027 Directions Structure: SINGLE FAMILY Hwy 64 East, Left on No Creek Rd. on Right just past Aubrey Merrell Rd. #of Bedrooms: 3 #of People: =Water Supply: PUBLIC System Specifications Minimum Trench Depth: 2 4 Site Classification: PS 71nches Minimum Soil Cover. Saprolite System? OYesONo Design Flow: 3 6 0 Maximum Trench Depth: 36es Soil Application Rate: 0 - 3 Maximum Soil Cover: Inches "System Classification/Description: "Distribution Type: GRAVITY-SERIAL 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: Oyes QQ No Pump Required: OYes QNo OMay Be Required Nitrification Field Sq. ft. Pump Tank: Gallons No. Drain Lines 1-Piece: Oyes ONo . Total Trench Length: 3 0 0 ft. GPM—vs-- ft. TDH Trench Spacing: _ QInches O.C. Dosing Volume: _ Gallons Feet O.C. g Trench Width: _ Inches Feet Grease Trap: Gallons Aggregate Depth: inches Pre-Treatment: ONSF OTS-1 OTS-li Septic Tank Installer Grade Level Required: 01 011 0111 OIV . . CDP Fild Number 124057 - 1 County ID Number: 5768402849 ❑ Open Pump System Sheet Repair System Required:QYes ONO ONO, but has Available Space rDesign System Trench Spacing: Inches O.C. ification: Ps Feet O.C. Trench Width: inches w: 3 6 0 - 0 Feet Soil Application Rate: 0 - 3 Aggregate Depth: inches `— Minimum Trench Depth: 2 4 *System Classification/Description: Inches TYPE IIA.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. Inches Maximum Trench Depth: 3 6 Inches *Proposed System: 25%REOUCTION Maximum Soil Cover: Nitrification Field Sq. Inches ft. No. Drain Lines *DistributionType: GRAVITY-SERIAL Total Trench Length:. 3 0 0 ft_ Pump Required: Oyes @No OMayOired Pre-Treatment: ONSF OTS-1 *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 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. 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 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 maybe 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? Oyes @No Applicant/Legal Reps. Signature: _ Date: "Issued By: 2244-Daywalt.Andrew Date of Issue: . 1 1 2 1 2 0 1 3 Authorized State Agent: Malfunction Log Oyes @Hand Drawing Olmport Drawing Total Time:(Fili:M1A) **Site Plan/Drawing attached.** 0 1 Hoes 0 0 Minutes • CONSTRUCTION AUTHORIZATION 124057 - 1 Davie County Health Department CDP File Number: 210 Hospital Street 5768402849 P.O.Box 848 County File Number: Mocksville NC 27028 Date: 1 1 / 2 1 / 2 0 1 3 Olnch Drawing Drawing Type: Construction Authorization Scale: ON-Ak ft. IV l o � IMPROVEMENT PERMIT For Office Use Only • , *CDP File Number 124057- 1 •"""'`- Davie County Health Department 'r 210 Hospital Street County ID Number.5768402849 P.O.Box 848 Evacuated For: NEW Mocksville NC 27028 Township: Phone:336-753-6780 Fax:336-753-1680 pERlJIT VALID UNTIL 11/18/2018 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: Scott Smith Property owner: Amanda Shoffner/Jodey Barber Address: 113 Fostall Drive Address: 607 Auril Hurt Road, Lot#15 Cly: Mocksville City: Lexington State2ip: NC 27028 State2ip: NC 27295 Phone#: (336)782-1647 Phone#: Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: No Creek Road Mocksville NC 27027 Directions Structure: SINGLE FAMILY Hwy 64 East, Left on No Creek Rd. on Right just past #of Bedrooms: 3 Aubrey Merrell Rd. #of People: *Water Supply: PUBLIC System Specifications nitial System (Site Classification:ica n: PS Minimum Trench Depth: 2 4 Inches aprolite System? OYes ONo Maximum Trench Depth: 3 6 Inches Design Flow: 3 6 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 0 • 3 1-Piece: OYes QNo 'System Classification/Description: Pump Required: OYes (D No OMay Be Required TYPE Ii A.CONY SYSTEM(SINGLE-FAMILY OR 460 GPD OR Pump Tank: Gallons LESS) `Proposed System: 25%REDUCTION 1-Piece: OYes ONo Repair System Required:QYes ONO ONO, but has Available Space r!Repair System *Site Classification: PS Minimum Trench Depth: 2 4 Inches Soil Application Rate: 0 3 Maximum Trench Depth: 3 6 Inches *System Classification/Description: Pump Required: OYes @No OMaybeRequired TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System: 25%REDUCTION Page 1 of 3 124057- 1 5768402849 .CDP Fite Number County ID Number. *Site Modifications ❑ Open Fill Sheet 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 way guarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. Site Plan The improvement Permit shall be valid for 6 years from date of Issue with a site plan(meaner a drawing not necessarily drawn to sale that shows the existing and proposed property lines with dimensions,the location of thefadlity and appurtenances,the O G site forthe proposed Wastewater system,and the location of water supplies and surtacewaters). Plat The Improvement Permit shall be valid without expiration with plat(means a property surveyed prepared by a registered land O surveyor,drawn to a sale of one Inch equals no more than 60 feet,that includes:the specific location of the proposed facility and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters. Plat also means,for subdivision lots approved by the local planning authority and recorded with the county register of deeds,a copy of the recorded subdivisions plat that Is accompanied by a site plan that Is drawn to scale). The Department and Local Health Department may Impose conditions on the Issuance and may revoke the permits for failure of the system to satisfy the conditions,the rules,or this article.This permit Is subject to revocation If the site plan,plat,or Intended use changes(NCOS 130A-335(f)).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)} Applicantfl_egal Reps. Signature Required? Oyes ONO Applicant/Legal Reps. Signature: Date: *Issued By: 2244-Daywalt,Andrew Date of Issue: 1 1 1 8 2 0 1 3 Authorized State Agent: Ot OValid without Expiration? O Create CA? 01-land Drawing Olmport Drawing **Site Plan/Drawing attached.** Total Time:(HI-I:Idlt) 0 1 Hours. 0 0 Minutes Page 2 of 3 Activitv Code: S4-IPS issued:new,valid for 60 mos. IMPROVEMENT PERMIT 124057- 1 • Davie County Health Department CDP File Number: 210 Hospital Street 5768402849 P.O.sox 848 County File Number: Mocksville NC 27028 Date: Qlnch ock Drawing Drawing Type: Improvement Permit Scale: . A ON/ QN/ 7 _._ I FT7 7 J 1 _ I Page 3 of 3 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Davie County Environmental Health p41D P.O.Box 848/210 Hospital Street -3 Mocksville,NC 27028 . 0'Jt/ (336)753-6780/Fax(336)753-1680 � �1 n pp kation For: VoSite f valuation/Improvement Permit ❑Authorization To Construct(ATC) Q 130th Type of Application: ew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility "'IMPORTANT'-'THIS APPLICATION CANNOT BEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billedf Sn,r Contact Person Billing Addres r-6.4.11 A\.— Home Phone City/State/ZIP Sy11 r ,` ; 7 07-6 Business Phone 33 G• 2•/G y� Name on Pemut/ATC if Di erent than Above nr. FAY 13QA ✓ Mailing Address J1jr2 Au,.fn. City/State/Zip `nr ^• N C -Z-7Z PROPERTY INFORMATION *Date House/Facility Comers Flagged NOTE: A survey plat or site plan must accompany this application. Included:211te Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat) Owner's Name Phone Number Owner's Address 4- City/State/ZipMarks...I/.- P 27rlth Property Address blo rt--,JL R&i city4apkyu e Lot Size Tax PIN#5L{Q%4U25j!'L mrd-0 G Subdivision N e(if applicable) Section/Lot# Directions To Site:IA%k tF fist- Na -Cry,x it -L -11�44- AG.& A-Ir_4t K,mi ►ti 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? Dyes Does the site contain jurisdictional wetlands? ❑Yes Are there any easements or right-of-ways on the site? ❑Yes Is the site subject to approval by another public agency? Dyes 00 Will wastewater other than domestic sewage be generated? ❑Yes IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms #Bathrooms�_ Garden Tub/Whirlpool❑Yes 94416 Basement:[]Yes No Basement Plumbing: ❑Y o 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 requesteConventional ❑Accepted ❑Innovative ❑Altemative ❑Other Water Supply Type:kc-unty/City Water ❑New Well ❑Existing Well ❑Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?❑Yes I�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 permits)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 d rule. I understand that I am responsible for the proper identification and labeling of property lines and comers and `tit,g an aggro g the house/facil' oca ion,proposed well location and the location of any other amenities. /�G� Site Revisit Charge Properry owner's or owner's legal representative signature Date(s): /,9, 2s,12 Client Notification Date: Date EHS: Sign given ❑Yes❑No Account# LWO Revised 11/06 Invoice# /!�� ■■■■■■■■■■■■■■■�� Iii■■■■■■ ■ ■■■■■■■■■■■■■■�i�■�.■■l■i■■■■■■ ■ ■■■■■■■■■■■■■ Ei%�■■■!■I■■■■■■■ ■■■■■■■■■■■■ro i/■■■■■■■1■!■■■■■■■ ■■■■■■■■■■■■ �■■■■■■■■■� ■■■■■■ ■■■■■■■■■■■■,H■■■■■■■■■■i ■■■■■■ ■■■■■■■■■■■■■I■■■■■■■■■ ■■■■■■ ■■■■■■■■■■■■,�■■■■■■■■■u■■■■■■■ ■■■■■■■■■■■■��■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■ffl■■■■■■■■■■ ■■■■■■■ ■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■ ■■■■■■■■■■■■�■■■■■■■ ■■■■■■■■■■■■�■■■■■■■■■■■�■■■■■■■ ■■■■■■■■■■■■.■■■■■■■■■■■ �■■■■■■■ ■■■■■■■■■■■■n■■■■■■■■■■ C■■■■■■■ ■■■■■■■■■wai■ ■■■■■■■■■■■�■ �■■■■■■ ■■■■■■■■■■■■ ■■■■■■■■■Emil 11■■■■■■ e■■■■■■■■■■i:■■ ■n■■■■i■il■■■■■■ ■■■■■■■■■■■■1■■ ■ ii �iii�iri� ` " ;i■■■■■■ ■■■■■■■■■■, ■�®■■■ . ■ ■■��■��■■■■■■ ■■■■■■■■■■ Il■I■■, ■i::�' '!�1■■■■■■ ■■■■ ■■■■■■��■®■ � ■I::��r'J■1 ■■■■■ ONE - NONE ®'i■■E■■ ■■■■■■I■■■■■■ ■■■■■■■■■■■■■rii■��::■.!!!■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ c V 1'450- [� t ' h g Y < m W 1Y �p 1 T - +•k r'' d dw - a c, d ai {d. i7t •� ��, r "ter - ( . , -. � S P, �ti t - _ - i✓?l . i G y Printed-.Oct 27, 2013 All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the implied 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 of the use or inability to use the GIS data provided by this website. • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 1 Z�vS 7 Tax PIN/EH#: J�7fe �.C�U•— Z��{9; Billed To: /,a� Subdivision Info: / Reference Name: 'C Location/Address: Proposed Facility: Property Size: Date Evaluated: 6 Water Supply: On-Site Well Community Public 1< I, Evaluation By: Auger BoringX Pit Cut FACTORS 1 2 3 4 .5 6 7 Landscape position Slope% d HORIZON I DEPTH 6-33 Texture group Consistence F12 Structure isle Mineralogy HORIZON II DEPTH. Texture group Consistence Structure 5 e Mineralogy ;I l HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH i Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE cc SITE CLASSIFICATION: rJ EVALUATION BY: ')4&1Pjej 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 l CONSISTENCE �41S1r 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 LYS 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-Lone-term acceptance rate- ual/davM2 rerun ntmc rve..:�oai; Davie County,NC - GoMaps Advanced Page 1 of I D. ie County,NC-GoMaps Advanced Iall r WR I •I t I� t� $Cts'fy 1 ' `•' � P r�r 2 `• 194 19t Latitude: 351 53 14,97' Longitudes-00°2V 20.94' http://maps2.roktech.net/davie_gomaps/index.htm] 11/15/2013 No u°�U o� h � l f i �-ro IT- s. � ww CJ\ol