155 Pool DrOPERATION PERMIT
14 Davie County Health Department
' 210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant:
Grace Boggs
Address:
155 Pool Drive
City:
Mocksville
State2ip:
NC 27028
Phone #:
(336) 998-5003
'CDP File Number 121299-1
County ID Number:
Evaluated For: EXISTING
1, Township:
Property Owner:
Address:
city:
State/Zip:
Phone #:
Property Location & Site Information
Address/Road #: Subdivision: Phase: Lot:
155 Pool Drive
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 2
# of People:
'Water Supply: PUBLIC
'IP Issued by. 2244 - Daywalt, Andrew
'CA issued by: 2244 - Daywalt. Andrew
Design Flow: 2 4 0
Soil Application Rate: 0 - 2 5
Nitrification Field
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Aggregate Depth:
Directions
64 East Left on Cornatzer. Pool Dr. on left past
Jametowne Dr. on Left
'System Classification/Description:
SaproliteSystem? QYes (E)No
'Distribution Type: NIA Pump Required?
QYes QNo
'Pre -Treatment:
Drain field
Sq. ft.
1
1 5 0 ft.
g1riches O.C.
Feet O.C.
()Inches
Feet
inches
Minimum Trench Depth:
Inches
Minimum Soil Cover.
Inches
Maximum Trench Depth:
Inches
Maximum Soil Cover: Inches
'System Type: INFILTRATOR QUICK 4 STANDARD
Installer: Sherman Dunn
Certification #:
'EH S: 2325 - Mitchell, Brittany
Date: 0 4/.2 5/ 2 0 1 3
Approval Status
El Approved ❑ Disapproved
CDP File Number 121299-1
, n
lAanufacturer
STB:
Gallons:
Date:
'Filter Brand:
ST Marker: ❑ Yes ❑ No
Reinforced Tank: ❑ Yes ❑ NO
",.,Piece Tank: ❑ Yes ❑ NO
Manufacturer.
PT:
Gallons:
Date:
/
Riser Sealed ❑
Yes
Riser Height: ❑
Yes
Reinforced Tank: ❑
Yes
Piece Tank: ❑
1-1,1,p_
Yes
otic Tank County ID Number:
Lot.
Long:
Installer:
Certification #:
'EHS:
Date: / /
Approval Status
❑ Approved ❑ Disapproved
Pump Tank
❑
No
❑
NO (Min.6 in.)
❑
No
❑
No
Pipe Size: inch diameter
Pipe Length: feet
`Schedule:
Pressure Rated ❑ Yes ❑ No
Approved fittings ❑ Yes ❑ No
Installer:
Certification #:
'EHS:
Date:
Approval Status
❑ Approved ❑ Disapproved
Supply Line
Installer:
Certification #:
'EHS:
Date:
Approval Status
❑ Approved ❑ Disapproved
/ 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
❑ Yes
❑
No
❑ Approved ❑ Disapproved
Vent Hole
❑ Yes
❑
No
\ Anti -siphon Hole
❑ Yes
❑
No
OPERATION PERMIT
. • �� OavieCountyHealth0epartment CDP File Number: �21299 - 1
210 Hospital Street
P.O.Box 848 County File Number:
Mocksviiie NC 27028 Date: 0 4 1 � 5 / � 0 1 3
\ L •J 1
Q Inch
Drawin� Drawing Type: Operation Permit Scale: , . , psiock = .ft.
QN/A
_ - _ __
_ _ _. _._
_
CoY�a�� �d '
_ Pao1 � Y• �"�
__ _ _ ___ _ _ _ __ _ _ _ _
� �
. . _ _ _ _ _ 1-� � '
13�
. �,�
40°� �° '
_ "1, _ gt �'' _. � _
hJ� -' - � /
l , � . � ��a°� . � �
1 .. ,� ..- �� � �
� h _
� �. ,
_ _ __ _ '
' y� •�'' - ' " ' _
' � . �
C
_ _ ts�u`` i4. . _ _ �Y, ��� _$�` _
4� _ ' '°`�`� ti _
� � , �
� - .
. _ .
.
,
,
� _ 3 5 ___: _ _ _
__ _ _ _ __ _ _ _ _ _ _ _ _ _
___
__ _ __ _ _ __ _ __ _ _ _
_ _ _ __ _ __ __ _ _ _ _ _ __ _
� ,
CDP File Number 121299 -1
Electric Eauinment
County ID Number: 252013
NEf,1A 4X Box or Equivalent
❑
Yes
❑
No
Installer:
Box 12 inches Above Grade
❑
Yes
❑
No
Certification 9:
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
El Approved El Disapproved
Alarm Visible
❑
Yes
El
No
2325 - Mitchell, Brittany
"Operation Permit completed by:
Authorized State Agent: Date of Issue: 0 4/ a 5/ a 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 fora homelbusiness owner must maintain a valid contract
with a public management entitywdh 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 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 priorto the
issuance of an Operation Permit for a system required to be maintained bya 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 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.
01 -land Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Activity Code: S -23C - O:P ISSUED - REPAIR 11
Total Time:(HHa,t1.1)
0 1 Hours 3 0 tlinutes
CONSTRUCTION
AUTHORIZATION
�-� Davie County Health Department
3 f¢� 210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Grace Boggs
Address: 155 Pool Drive
City: Mocksville
State2ip: NC 27028
Phone #: (336) 998-5003
(/Address/Road #: Subdivision:
155 Pool Drive
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 2
# of People:
*Water Supply: PUBLIC
/ For Office Use Only
'CDP File Number 121299-1
County ID Number:
Evaluated For: EXISTING
�, Township:
Property Owner:
Address:
City:
StatefZip:
Phone #:
0 4/ 1 9/ 2 0 1 8
Phase: Lot:
Directions
64 East Left on Cornatzer, Pool Dr. on left past
Jametowne Dr. on Left
Page 1 of 3
Minimum Trench Depth: 0
Site Classification:
Inches
Saprolite System? QYes QNo
f�tinimum Soil Cover.
Inches
Design Flow:
fAaximum Trench Depth:
Inches
Soil Application Rate:
.
Maximum Soil Cover:
Inches
`System Classification/Description:
`Distribution Type:
TYPE II A. COW SYSTEM (SINGLE-FAMILY
OR 480 GPD OR LESS) Septic Tank:
Gallons
'Proposed System: 25% REDUCTION
1 -Piece: QYes
QNo
Pump Required: QYes QNo
Qh1ay Be Required
Nitrification Field
Sq. ft. Pump Tank:
Gallons
No. Drain Lines
1 -Piece: QYes
QNo
Total Trench Length:
ft GPIrt—vs--
ft. TDH
Trench Spacing:_
QInches O.C.
Feet O.C. Dosing Volume: _
Gallons
Trench Width:
Inches
8Feet
—
Grease Trap:
Gallons
Aggregate Depth:
inches Pre -Treatment: ONSF OTS -1 OTS -II
Septic Tank Installer Grade Level Required: 01 Oil OIII OIV
Page 1 of 3
IADP File Number 121299 -1
County ID Number:
❑ Open Pump System Sheet
A �
air bystem Requireo:lJTes vivo IJIVu, but na5 Available 5
' Trench Spacing: Inches 0.
*Site Classification: PS — 8Feet O.C.
Trench Width: Olnches
Design Flow: a 4 0 _ C7 Feet
Soil Application Rate:Aggregate Depth;
0 - a 5 inches
*System Classification/Description: Minimum Trench Depth: Inches
TYPE 11 A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover.
Inches
*Proposed System: 25%REOUCTION Maximum Trench Depth: Inches
Maximum Soil Cover:
Nitrification Field Inches
Sq. ft.
No, Drain Lines *Distribution Type: GRAVITY- SERIAL
Total Trench Length: 1 5 0 ftPump Required: OYes ONo 01-Aay Be Required
11-1 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 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.
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(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)).
ApplicanVLegal Reps. Signature Required? Oyes ONo
Applicant/Legal Reps. Signature: Date: - / /
*Issued By;
2244 - Daywalt, Andrew
Authorized State Agent:
Date of Issue: 0 4/ 1 9'/ x 0 1 3
Malfunction Log Oyes
OHdnd Drawing Oimport Drawing TotalTime:(HH:M1.1)
**Site Plan/Drawing attached.**
Page 2 of 3 Hours 3 Minutes
S-10 - CIA ISSUED - REPAIR
• CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Construction Authorization
Poo l
CDP File Number:
County File Number:
Date: 04/ 1 9/ 2 0 1 3
Q Inch
Scale: OBlock
QN/A
- - '
IMPROVEMENT PERMIT
-`.
Davie County Health Department
CAY
�f
State/Zip:
NC 27028
210 Hospital Street
(336) 998-5003
P.O. Box 848
Mocksville NC 27028
For Office Use Only
*CDP File Number 121299 - 1
County ID Number:
Evaluated For: EXISTING
Township:
Phone: 336-753-6780 Fax: 336-753-1680 PERIJIT VALID UNTIL: 4/19/2018
*NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit.
Applicant:
Grace Boggs
Address:
155 Pool Drive
CAY
Mocksville
State/Zip:
NC 27028
Phone "":
(336) 998-5003
Address/Road #:
155 Pool Drive
Mocksville
Structure:
9 of Bedrooms:
9 of People:
*Water Supply:
NC 27028
SINGLE FAMILY
2
PUBLIC
Saprolite System?
Design Flow:
Soil Application Rate:
Subdivision:
rr
roperty Owner:
ddress:
ily:
State/Zip:
Phone #:
ite Information
Phase:
Lot:
Directions
64 East Left on Cornatzer, Pool Dr. on left past
Jametowne Dr. on Left
cations
Minimum Trench Depth: 0 Inches
OYes C)No Maximum Trench Depth:
Inches
Septic Tank:
*System Class ifiication/Description:
TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR
LESS)
*Proposed System: 25% REDUCTION
1 -Piece:
Pump Required
Pump Tank:
1 -Piece:
Repair System Required: 0 Yes ONO ONO, but has Available Space
/ ReaaIr System
*Site Classification: PS
Soil Application Rate: 0 a 5
*System Classification/Description:
TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR
LESS)
*Proposed System: 25% REDUCTION
Gallons
OYes ONo
OYes ONo OMay Be Required
Gallons
OYes ONo
Minimum Trench Depth: Inches
Maximum Trench Depth: Inches
Pump Required: OYes ONo O May be Required
Pagel of 3
-CDP Ftile Number 121299-1 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 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.
Site Plan The Improvement Permit shall be valid for 5 years from date of issue with a site plan (means a drawing not necessarily drawn to
O scale that shows the existing and proposed property lines with dimensions, the location of thefadtity and appurtenances, the
site forthe proposed Wastewater system, and the location of water supplies and surfacewaters).
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 scale of one inch equals no morethan 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 (NCGS 13OA-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 (A 938(b)).
ApplicantlLegal Reps. Signature Required? Oyes ONO
ApplicanVLegal Reps. Signature:,
Date:
'Issued By: 2244 - Daywalt, Andrew Date of Issue: 0 4 / 1 9 / a 0 1 3
Authorised State Agent: OValid without Expiration?
QCreate CA?
OHand Drawing Olmport Drawing
**Site Plan/Drawing attached.** TotaiTime:(HH:I.tl.t)
0 Hours 3 0 rr inutes
Page 2 of 3
Activdv Code: S-6 - IP'S issued: repairs
' ' IMPROVEMENTPERMIT 121299 - 1
. • Davie County Health Department CDP File Number:
210 Hospital Street
P.o.eox 8as County File Number:
Mocksvitle ntc 27o2s Date: I I
Q Inch
Drawin� Drawing Type: Improvement Permit Scale: ` . , pBfock _� .
QN/A — ft.
___ _----. ___ _ ____ _ __ . _____ __ __.___ _ _ _ _ __ _ . __
;
_ ��C ,L,,t _ _
. _ _ _ . _ __ _ _ .
�� � :
,
� �. _ __ _ _ __ __
�
l3�
_ _ '! _ � � _ _
5I
.
. _ _...,. �� _ :_
; , _ i
,
' 2 �s �'�i�K�,' ; '
v �
. � _ :
,
_ . _ �
� � _
_ � ;
. ' ' 3� ' _ ' _
; ,
_ _ _ _ , _ _ _ _ _ � _ _
_ _
, __
; �
;
_ ,_ _ . _ _ _ __ ___ __ _ _ ___ _ __ _ __ _ __ . _ _ ___
. , ;
. _ _ _
_
_ _
Page 3 of 3
• DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680
REPAIR OPERATION PERMIT
Account #: 990005747
Billed To: Grace Boggs
Reference Name: REPAIR PERMIT
Proposed Facility: Residential Repair
Tax PIN/EH #: 5759-90-6664
Subdivision Info:
Localion3Address: 155 Pool Drive -27028
Property Size: 1.69 Acers
ATC Number: 5819
**NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC has been installed
in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "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.
/ ( 1
System Type: S.T. Manufacturer Tank Date Tank Size-,---'
Pump Tank Size /
System Installed By:�V\Qi�%1f^i� > {�� E.H. Specialist: M) i{ ate: �fXl
GPS Coordinate:
IG;
DCHD 11/06 (Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780/ Fax # (336)753-1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990005747
Tax PKiEl1 #: 5759-90-6664
Billed To: Grace Boggs Subdivision Info:
Reference Nanne: REPAIR PERMITLocalionfAddress: '155 Pool Drive -27028
Proposed Facility: Residential Repair Prop �',�Y&01;@R PSPRl�air ❑Expansion
�TCe I?ep��r'�glq
ATWfibtr'hi�6&lighorization to Construct (ATC) MUST :BB ISSUED by the Davie County Environmental
Health Section prior to.issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A
Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat
or the intended use change.
Residential Specifications: # Bedrooms Z # Bathrooms # People Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People —# Seats
Square Footage(or Dimensions of Facility)
Lot SizeI .T Type of Water Supply: ❑County/City ❑Well ❑Community Well
f'
System Specifications: Design Wastewater Flow (GPD) qQ Tank Size AL. Pump Tank GAL.
%. I•
Trench Width Max. Trench Depth,36 Rock Depth6U//A Linear Ft. ,S%
Site Modifications/Conditions/Other:
Contact the Davie County Environmental Heilth Section for final inspection of this system between
8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760.
Environmental Health Specialist
DCHD 11/06 (Revised)
12_Vq
4
-Too o;e* _220
NAM
ADD
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
ONE NUMBER qq?_ 5663
BDIVISION NAME
/ LOOT #
DIRECTIONS TO SITE Y' ��%�57 �°f�' diU ('niA144eX, .6461/ bk
Le
. -
DATE SYSTEM INSTALLENAME SYSTEM INSTALLED UNDER No IZrrCOZa
TYPE FACILITY PJ NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTEINFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge. and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93
GoMaps GIS
Page 1 of 6
OC
http://maps.co.davie.nc.us/GoMaps/map/map.cfm?CFID=4129&CFTOKEN=61640881 8/29/2011