220 Oak Grove Church RdApplicant: William Beetling
Address: 220 Oak Grove Church Rd
City: Mocksville
State/Zip: NC 27028
Phone #:
Address/Road #: Subdivision:
220 Oak Grove church Rd
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
*Water Supply: N/A
*IP Issued by: 2140 - Nations, Robert
*CA issued by: 2140 - Nations, Robert
Design -Flow: 3 6 0
Soil Application Rate: 0 4
Nitrification Field
No. Drain Lines a
Total Trench Length: 3 ft.
Trench Spacing: 9 0Inches O.C.
®Feet 0. C.
Trench Width: – 3 Q Inches® Feet
Aggregate Depth: 1 a inches
`CDP File Number 122958-1
1-15-000-00-031
County ID Number:
Evaluated For: REPAIR
",,–Township:
Property Owner: William Beeding
Address: 262 Pinebrook School Rd
City: Mocksville
State/Zip: NC 27028
Ph�—
Phase: Lot:
Directions
hwy 158 east right on Oak Grove Church Rd.
9 0 0 Sq. ft.
*System Classification/Description:
Saprolite System? O Yes 9 No
*Distribution Type: GRAVITY - SERIAL Pump Mired?
O Yes No
*Pre -Treatment:
Minimum Trench Depth: D
OPERATION PERMIT
Minimum Soil Cover: 1
Davie County Health Department
Maximum Trench Depth: 3
210 Hospital Street
�w r.
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: William Beetling
Address: 220 Oak Grove Church Rd
City: Mocksville
State/Zip: NC 27028
Phone #:
Address/Road #: Subdivision:
220 Oak Grove church Rd
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
*Water Supply: N/A
*IP Issued by: 2140 - Nations, Robert
*CA issued by: 2140 - Nations, Robert
Design -Flow: 3 6 0
Soil Application Rate: 0 4
Nitrification Field
No. Drain Lines a
Total Trench Length: 3 ft.
Trench Spacing: 9 0Inches O.C.
®Feet 0. C.
Trench Width: – 3 Q Inches® Feet
Aggregate Depth: 1 a inches
`CDP File Number 122958-1
1-15-000-00-031
County ID Number:
Evaluated For: REPAIR
",,–Township:
Property Owner: William Beeding
Address: 262 Pinebrook School Rd
City: Mocksville
State/Zip: NC 27028
Ph�—
Phase: Lot:
Directions
hwy 158 east right on Oak Grove Church Rd.
9 0 0 Sq. ft.
*System Classification/Description:
Saprolite System? O Yes 9 No
*Distribution Type: GRAVITY - SERIAL Pump Mired?
O Yes No
*Pre -Treatment:
Minimum Trench Depth: D
4
Minimum Soil Cover: 1
a
Maximum Trench Depth: 3
6
Maximum Soil Cover: a
4
Inches
Inches
Inches
Inches
Page 1 of 4
*System Type: INFILTRATOR QUICK 4 STANDARD
Installer: Brian McDaniel
Certifteation #:
*EHS: 2140 - Nations, Robert
Date: 0 8/ a a/,2 0 1 3
Approval Status
® Approved ❑ Disapproved
CDP File Number 122958 - 1
County ID Number: 1-15-000-00-031
Manufacturer:
shoaf
Lat.
Dosing Volume:
Date:
Long:
,
STB:
Yes
❑
No
Riser Height: ❑
Yes
❑
1000
nforced Tank: ❑
Yes
Installer:
Brian McDaniel
Gallons:
Yes
❑
No
❑
No
Date:
0 5/
0 4/.1
0
1 3 Certification #:
Check -valve
❑
Yes
❑
*EHS:
2140 - Nations, Robert
*Filter Brand:
POLYLOK PL -525
Yes
❑
No
Vent Hole
❑
Yes
❑
0 8/ a a/ a 0 1 3
ST Marker:
[:1 Yes
®
NO
Date:
NO
nforced Tank:
® Yes
❑
No
Approval Status
❑
Approved ❑ Disapproved
1 Piece Tank:
\
❑ Yes
®
No
Pump Tank
Manufacturer:
PT:
Pump Type:
Gallons:
Dosing Volume:
Date:
-
Riser Sealed ❑
Yes
❑
No
Riser Height: ❑
Yes
❑
NO (Min. 6 in.)
nforced Tank: ❑
Yes
❑
No
1 Piece Tank: ❑
Yes
❑
No
/ Pipe Size: inch diameter
Pipe Length: feet
*Schedule:
Pressure Rated ❑ Yes ❑ No
Approved fittings ❑ Yes ❑ NO
/
Pump Type:
Dosing Volume:
-
Draw Down:
Inches
*Chain:
Valves Accessible
❑
Yes
❑
No
Flow Adjustment Valve
❑
Yes
❑
No
Check -valve
❑
Yes
❑
NO
PVC Unions
❑
Yes
❑
No
Vent Hole
❑
Yes
❑
No
Anti -siphon Hole
❑
Yes
❑
NO
Installer: Brian McDaniel
Certification #:
*EHS:
Date:
Approval Status
❑ Approved ❑ Disapproved
_J
pply Line
Installer: Brian McDaniel
Certification #:
*EHS:
Date: / /
Approval Status
❑ Approved ❑ Disapproved
Installer: Brian McDaniel
Gal Certification #:
*EHS:
Page 2 of 4
Date: / /
Approval Status
❑ Approved ❑ Disapproved
CDP File Number 122958 - 1
County ID Number: H5-000-00-031
NEMA 4X Box or Equivalent
❑
Yes
❑
NO
Installer:
Brian McDaniel
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
❑
Yes
❑
NO
❑
Approved ❑ Disapproved
Alarm Visible
El
Yes
ElNO
2140 - Nations, Robert
*Operation Permit completed
Authorized State Agent:
Date of Issue: 0 8/.2 1/.1 0 1 3
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 sewage septic system.
Rule .1961 requires that a Type septic system meet the following criteria:
Minimum System Review By The Local Health Department:
Management Entity:
Minimum System Inspection/Maintenance Frequency By Certified Operator:
Reporting Frequency By Certified Operator:
Rule .1961 requires that a Type IV and V septic systems designed for a home/business owner must maintain a valid contract
with a public management entity with a certified operator or a private certified operator for the life of the septic system.
Rule .1961 requires that Type VI septic systems designed for a home/business owner must maintain a valid 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 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 O Import Drawing
**Site Plan/Drawing attached.**
Activity Code: S-19 2Q4 - OP issued NEW Type II Quick 4
Page 3 of 4
Total Time:(HH:MM)
0 a Hours 3 0 Minutes
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Operation Permit
a8?
CDP File Number: 122958 - 1
County File Number: H5-000-00-031
Date: 0 8/ .2 1 x 0 13
O Inch
Scale: O Block
(9 N/A
Page 4 of 4 P1 P2 P3
Applicant
Address:
City:
State2 ip
Phone
CONSTRUCTION
AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
f For Office Use OnIY
"CDP File Nurnber 122958-1 V
County ID Number: H5.000.00.031
Evaluated For: REPAIR
, Township:
0 8/ 2 1/ 2 0 1 8
William Beeding Property Owner: William Beeding
220 Oak Grove Church Rd Address: 262 Pinebrook School Rd
Mocksville City. Mocksville
NC 27028 State!Zip: NC 27028
� AddresstRoad
220 Oak Grove church Rd
Mocksville NC 27028
Structure: SINGLE FAMILY
of Bedrooms: 3
of People:
"Water Supply: N'A
Subdivision:
Phone »:
Phase: Lot:
Directions
hwy 158 east right on Oak Grove Church Rd.
System Specifications
/
Minimum Trench Depth: 2 4\
,Site Classification: PS Inches
Minimum Soil Cover.
Saprolrte System? OYes ONo Inches
Design Flow: 2 4 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: Maximum Soil Cover:
0 3 Inches
`System Classification/Description: 'Distribution Type: GRAVITY - SERIAL
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
`Proposed System: 253;. REDUCTION
Nitrification Field
No. Drain Lines
Total Trench Length
2 0 0 ft.
Septic 'r f,
1 0 0 0 Gallons
1 -Piece: OYes ONo
Pump Required: ()Yes ONo ()faay Be Required
Sq. ft. Pump Tank: Gallons
1 -Piece: ()Yes Otto
GPI.1—vs-- ft. TDH
Trench Spacing: — Inches O.C.
_8Feet O.C. Dosing Volume: Gallons
Trench Width: Inches
— _ JFeet Grease Trap: Gallons
Aggregate Depth:
inches Pre -Treatment: ONSF OTS -1 OTS -II
Septic Tank Installer Grade Level Required: OI OII 0111 OIV
Pagel of 3 NUUiciztF 1 r0Z2
. .
CQPFile Plumber 122958 - 1
ReDaif Svstem
'Site Classification:
Design Flom:
Soil Application Rate:
*System Classification !Description:
'Proposed System:
N rtnfication Field
No. Drain Lines
County ID Number: H5-000-00.031
El Open Pump System Sheet
uired:OYes ONo ONo, but has Available Space
Trench Spacing:
Inches 0.
8—
Feet O.C.
Trench Width:
0 inches
_ OFeet
Aggregate Depth:
inches
Minimum Trench Depth:
Inches
t; inimum Soil Cover.
Inches
Maximum Trench Depth:
Inches
Maximum Soil Cover:
Inches
Sq. ft.
'Distribution Type:
Total Trench Length: Pump Required: QYes ONo 010ay Be Required
ft.
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.
'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 lime 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 lays, rules, and permit conditions regarding system location, installation, operation, maintenances monitoring. reporting and repair
(1938(b)).
ApplicantfLegal Reps. Signature Required? QYes (--)No
ApplicanVLegal Reps. Signature, Date: /
'Issued By: 2244 - Daywalt. Andrew Date of Issue: 0 8 / 2 1 / 2 0 1 3
Authorized State Agent. faalfunction Log QYes
OHand Drawing Olmport Drawing Total Time:(HHJ,11.1)
**Site Plan/Drawing attached.**
Page 2 of 3 1 Hours t.t mutes
S-10 - CXS issued - repair
CONSTRUCTION AUTHORIZATION
. Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Construction Authorization
t
..
kA 56
Panp 3 of 3
CDP File Number: 122958 - 1
County File Number: H5-000.00-031
Date: 08/21 /2013
•J
Olnch
Scale: OBlock ft.
ON/A
T