131 S Benson Ln A
OPERATION PERMIT ice se n v
Davie County Health Department F,*CDPumber 122867-1
210 Hospital Street Ls-o2D-Ba017
P.O.Box 848 mber.
Mocksville NC 27028 Evaluated For: REPAIR
Phone:336-753-6780 Fax:336-753-1680 Township:
Applicant: David J. Piff Property Owner. David J. Piff
Address: 131 S. Benson Lane Address: 131 S. Benson Lane
City: Mocksville City: Mocksville
State2ip: NC 27028 'State2ip: NC 27028
Phone#: Phone#:
Property Location & Site Information
Address/Road#: Subdivision: Twin Cedars Phase: Lot: 17
131 S Benson Lane
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 601 South, Left on Deadmon Rd, Right on Wait
Wilson Rd. to Benson
#of Bedrooms: 3
#of People:
*Water Supply: PUBLIC
*IP Issued by. *System Classification/Description:
'TYPE Il A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by:
Saprolite System? OYes QkNo
Design Flow: 3 6 0 * GRAVITY-SERIAL. Pump Required?
Distribution Type: OYes allo
Soil Application Rate: 0 - 3 *Pre Treatment:
Drain field
rNonDratin
ican Field 1 a 0 0 Sq.g• *System Type: INFILTRATOR OUICK 4 STANDARD
Lines 3Installer: Randy Miller
Total Trench Length: 3 0 0 g• Certification#: 1128
Trench Spacing: — 9 Inches O.C.
()Inches
O.C. *EHS: 2140-Nations.Robert
Trench Width: 3 Inches
&Feet Date: 0 4 / 1 4 / .2 0 1 4
Aggregate Depth: inches
Minimum Trench Depth: 3 6
Inches
Minimum Soil Cover. a 4 ApprovaM Status
Inches
Maximum Trench Depth: 3 6 ® Approved D Disapprovetl
Inches
Maximum Soil Cover.
2 4 Inches
CDP Fite Number 122867 - 1 County ID Number: LS-020-so-017
Septic Tank
Manufacturer. Lata
Long:
STB:
Gallons: Installer.
Date: Certification#:
*EHS:
'Filter Brand:
ST Marker. ❑ Yes El No
Date:
ReiMorcedTank: ❑ Yes El No � ApprovaiStatus
Piece Tank: ❑ Yes ❑ No =❑ Approved❑ =Dlsapproved
- Pump Tank
Manufacturer. Installer.
PT: Certification#:
Gallons: THS:
Date: ! 1 Date.
RiserSealed ❑ Yes ❑ No
❑RiserHeght: ❑ H.
Approval Status
einforcedTank: 103 Yes ❑ No Q Approved❑ Disapproved
i Piste Tank: ❑ Yes ❑ No
Supply Line
Pipe Size: inch diameter Installer.
CPipe-Length: feet Certification#:
THS:
*Schedule:
Pressure Rated ❑ Yes ❑ No Date:
Approved fittings ❑ Yes ❑ No ApprtnratStatus
❑ Approved❑ Dlsapproved
Pump Requirement
CDosing
mp Type: Installer.
Volume: — Gal Certification#:
aw Down: Inches THS:
'Chau:
Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve ❑ Yes ❑ No Ap"provai Status ;
PVC Unions El Yes O No ❑ gppraved❑ Dlsapproved. _.
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole El Yes ❑ No
CDP File Number 122867 - 1 County ID Number: t.5-020.80-017
Electric E ui ment
NEMAdX Box or Equivalent ❑ Yes ❑ No Installer.
Box 12 inches Above Grade ❑ Yes ❑ NO Certification#:
Box Adj. Pump Tank ❑ Yes ❑ No
Conduit Sealed ❑ Yes ❑ NO 'EHS:
Pump Manually Operable ❑ Yes ❑ NO
*Activation Method: Date:
Approval Status
Alarm Audible ❑ Yes ❑ No ❑ Approved❑ Dlsappoved
Alarm Visible ❑ Yes 13N0 =
2 0 -Nations.Robert
*Operation Permit completed by:
Authorized State Agent: Date of Issue: 0 4 / 1 0 / 0 1 4
Owner/Applicant Signature:
This system has been installed in compliance wilh applicable NC General Statutes:Article 11, Chapter 130A, Rules-for.
Sewage Treatment and Disposal,15A NCAC 1 B .1900 et. Seq.,and all conditions of the Improvement Permit and
Construction Authorization.This property Is served by a TYPE a A. sewage septic system.
Rule.1961 requires that a Type TYPE IIA 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:
NIA
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 a valid contract with a
public management entitywith 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 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.
OHand Drawing Olmport Drawing
**Site Plan/Drawing attached.** `'
OPERATION PERMIT 122867- 1
Davie County Health Department CDP File Number:
210 Hospital Street 1.5.020-80-017
P.O.Box 848 County File Number:
Mocksvilte NC 27028 Date: i
Q Inch
Drawing Drawing Type: Operation Permit Scale: , OON A k
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I I I I I
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CONSTRUCTION For office Use Only
AUTHORIZATION *CDP File Number 122867-1
°"- Davie County Health Department County ID Number. L5-020-BO-017'17
t 210 Hospital Street Evaluated For. REPAIR
�•oa,;,.. P.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 0 8 / .2 0 / .1 0 1 8
Applicant: David J. Piff Property Owner. David J. Piff
Address: 131 S. Benson Lane Address: 131 S. Benson Lane
City: Mocksville City: Mocksville
State0p: NC 27028 State/Zip: NC 27028
Phone#: Phone#:
Property Location & Site Information
Address/Road#: Subdivision: Twin Cedars Phase: Lot: 17
131 S Benson Lane
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 601 South, Left on Deadmon Rd, Right on Walt
Wilson Rd.to Benson
#of Bedrooms: 3
#of People:
I ater Supply: PUBLIC
System Specifications
Minimum Trench Depth:
Site Classification: Ps Inches
Minimum Soil Cover.
Saprolite System? O Yes 9 No Inches
Design Flow: Maximum Trench Depth:
Inches
Soil Application Rate: Maximum Soil Cover.
Inches
*System Classification/Description: *Distribution Type:
Septic Tank:
Gallons
*Proposed System: 1-Piece: O Yes O No
Pump Required: O Yes O No O May Be Required
Nitrification Field
Sq.ft. Pump Tank: Gallons
No. Drain Lines 1-Piece: OYes ONo
Total Trench Length: ft GPM—vs— ft. TDH
Trench Spacing: QFeet O.C. Dosing Inches O.C.
— O Volume: Gallons
Trench Width: Inches
Feet Grease Trap: Gallons
Aggregate Depth: inches
Pre-Treatment: O NSF OTS-1 OTS-II
Septic Tank Installer Grade Level Required: 01011 O 111 ON
Page 1 of 3
AFile Number 122867 - 1 County ID Number. L5-020-BO-017
❑ Open Pump System Sheet
Repair System Required:0 Yes O No O No, but has Available Space
rDesignFlow:
System Trench Spacing: 9 Inches O.C.
ification: PS — W Feet O.C.
Trench Width: Inches
3 6 0 - 3 60 Feet
Soil Application Rate: 0 3 Aggregate Depth: inches
.� Minimum Trench Depth: a 4 Inches
*System Classification/Description:
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Minimum Soil Cover:
LESS) Inches
Maximum Trench Depth: 3 6 Inches
*Proposed System: 25%REDUCTION
Maximum Soil Cover.
Nitrification Field Inches
Sq.ft.
No. Drain Lines *Distribution Type: GRAVITY-SERIAL
Total Trench Length: 3 0 0 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.
*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 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(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? Oyes ONO
Applicant/Legal Reps. Signature: Date:
*Issued By: 2244-Daywalt,Andrew Date of Issue: 0 8 / a 0 a 0 1 3
Authorized State Agent: Malfunction Log (&Yes
®Hand Drawing O Import Drawing Total Time:(HH:MM)
**Site Plan/Drawing attached.`* 0 1 Hours 0 0 Minutes
Page 2 of 3
S-10-CAS issued-repair
CONSTRUCTION AUTHORIZATION 122867 - 1
Davie County Health Department CDP File Number:
` 210 Hospital Street L5-020-130-017
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 0 8 / a 0 / a 0 13
O Inch
Drawing Drawing Type: Construction Authorization Scale: . O Block
O N/A
p
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I '
Page 3 of 3
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CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street C File umber: 122867 - 1
P.O.Box 848 L5-020-BO-017
Mocksville NC 27028 C un File umber:
ate: .0 8 / .10 / a013
Click below to import an image from an external location: Drawing Type: onst tion uthorization
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