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459 Shady Knoll Ln , _ _ _ _ _ __ _ _ _ _ _ _ _ _ . OPERATI4N PERMIT or ice se n v Davie County Health Department *CDP,File Nambe� 187,728-1 ' ��•� � _ - _ . 210 Hospital Street � ' . , : �� P.O. Box�84$�� County ID,Numt�er:. �r,��✓_ . Macksville;: NC� 27028: ' Evaluated For. REPEIIR� Phone:336-753-6780 Fax:336-753-1680 Township: Appiicant: �im CartneriRental Property Prnperty owner._,�im CartnedRental Property . � Address: 459 Shady Knoll Lane Address: 1�08 Cross Pond Drive � C�Y� Mocksvilie ��Y� Cotfax � state2ip: NC 27028 State2ip: NC 27239 Phone#: t336)817-6573 Phone#: (336)$17-fi573 Pro e Location 8 Site Information Address/Road#: Subdivision: Phase: Lot: 459 Shady Knoll Lane Mocksville NC 27028 Directions structure: SINGLE FAMILY Down by South Davie, Jericho Ch Rd. tums into Davie Academy, stay to right on Davie Academy, #of Bedruoms: 3 Shady Knoll on right. �of People: "Wete�Supply: EXISTING WELL 'IP Issued by. 2taa-Nauons,R� "System Classifaation/Description: ' TYPE il A.:CONV SYSI'�M{SINGIE•FAMIE.Y OR d80 GPD iJR LESSj "CAissuedby: 2�ao-r�auons,Robert SaprotiteSys#em? QYes QNo Design Flow: 3 6 0 * GRAviTY-PARALLEL Pump Required? Oistribution Type: (eq.d-box) QYes QNo Soil Application Rete: � , a � 5 •p�Treatment: Drain fleld N�rification Field 1 3 � 9 SQ-ft� 'System Type: �NFILTRATOR�UICK d STANDARD No.Drain Lines 3 Instaper. Brian McDan�1 Totat Trench l.ength: � 3 3 a �• Certification#: Trench Spacing: _ g Inches O.C. ,_,� ,_,.._.. +r Feet G.C. 'EH S: 2140-Nat�ns.Rabe�t Trench Width: 3 (nches - . . F�t oete: � 1 / a � / aeis W W Aggregate Depth: inches Minimum Trench Depth: 3 6 inches Minimum Soit Cover. a 4 °Approval�#atus: Inches , , �� ,�: �� •Mazimum Trench De th- k ` P , �3 6 _ � .;}�pproved CI��isappro��:+� inches Maximum Soil Cover: a 4 �nches __ ._ _ � CDP File Number �8�728 " � County ID Numh�er: Se tic Tank Manufacturer. Lat. � Long: , STB: � � Gallons: Instaqer. Date: � � Cettification#: 'EH S: "Filter Brand: � / ST Marker. ❑ `Y'Qg ❑ Np Date: Reinforced Tank: ❑ YeS ❑ N O �� i��;��5 �� 9 Piece Tank: p Yes O No 'C� App"rov+ed CI =D�sappraried Pump Tank Manufacturer. InstaUer. pT; Certification#: G allons: 'E��. Dat�: i � Date: � � tt�serseaied D Yes ❑ No RiserHeght: D Yes ❑ Nt? �Min.6 in.} � � �'�s ' ��=` A�p�alStatus� �'�" R�info�ced Tank: ❑ Yes ❑ No �� r�:'ApProved O D�s�pprave� 1 Pieoe Tank: O Yes ❑ NO Sup�ply Line Pipe Size: inch diametec tns#a�er: Pipe Length: feet Certification#; *Schedule: *EH S: Pressure Rated ❑ YeS ❑ No Oate: 1 � Approved fidtings ❑ YeS ❑ NO � Approvsi Stefus�- �; ` F , �C] Approue�� Disappraved° j "__�� aa � .n�.:� � �F Pump Type: InstaQe� Dasing Volume: — ,�� Certificatian#. � - Draw Down: Inches ��S' *Chaan: � � D�te: Valves Accessible O Yes ❑ NO Flow Adjustment Vaive ❑ yg� ❑ �Jp check-vatve O Yes ❑ No Appravai statusT'. Pvc,unions, l� '�es ❑ Na ��. G7:,Approved C7 [�tsappro�►ed � �. Vent HoJe ❑ Yes ❑ N o ��n�.rF�. r�� ., , �- ��a�3 Anti-siFhon Hole ❑ Y�S ❑ NO � _ _ _ _ _ __ _ _ __ _ . _ _ _ _ CDP File Number 187728- 1 County ID Number: , Etectric E ui ment NEMA 4X Box or Equivalent ❑ YeS ❑ NO InstaMer. Box 12 inches Above Grade ❑ Y�S ❑ NO CertificaGon#: � Box Adj.To Pump Tank ❑ Yes ❑ No Conduit S$aled ❑ yes ❑ No "EHS: Pump ManuallyOpera6le ❑ Yes ❑ NO / ' 'Activation Method: Date: Alarm'Audible ❑ Yes �� No : Apprc�yal S#�t�s 3` � 4 � ; Alarm Visible ❑ Yes � Na � 'A p proved❑ D�sa p provedp �,� � �_F 2140-Nations.Robert *Operation Permit completed by Authorized State Agent: Date of Issue: � 1 / a 0 � a 0 1 5 OwneNApplicant Signature: This system has been installsd in comptiance w�h applicable NC General Statutes:Articfe 11� Ghapter 130A,Rules far Sewage Treatment and Disposa1,15A NCAG i8A:1900 et.Seq.,end aa conditions ot the Improvement,Pe�it and Construction Authorization.This property is setved by.a 1'YpE p A. SE1Mag� S�p�IC SySt@t7'i., Rule.196i requires thet a Type ��A septic system meet the fotlowing criteria:: Minimum System Review ByThe Local Health Department: wA Management Entity: ��ER Minimum System Inspection/Maintenance FrequencyByCertified Operator. WA Reporting F�equency By Certified Operator.wA Rule.1_961 requires that a Type IV and V septic sy�tems desgned for a homelbusiness owner mus#maintain a valid contract w�h a pubtic`management entity w�h a certified operatoror a private ce�ified operator forthe life of the septic system. Rule.1961 requlres that Type VI septic systems designed for a home/business owner must maintain a valid�contract with� public management entity with a certified operator for the tifa of the septic system. Rule. 1961,(2)(e)requires a contract shall be executed between the system owner and a management ent�y priar to the issuance ofi an Operation�eRnit for e`system required tv be meintained bys pubGc.o�private management ent�Ty,unless;the system ownerand certified operator are the same; The contract shall require sp�cif�c requ�ements forma��enance and operafion, �esponsibiities of the ownerand systems aperator,provisions#hat the contract shall be in effect.for as tong as#hs system is in use,and otherrequirements for the,continued proper pe�formance of the system. ik shall also be a contlkion of �the Operation Pennit fhat subsequentiowners of the systems execute such a contract. �Hand Orawing 4lmport Drawing ��. � **Site PIanlDrawing attached.** �� `�"�'��: _ _ _ _ _ _ _ __ _ �. QPERATION PERMiT ,�$�7�$ � ,� DavieCountyHealthDepartment CDP Fil� Number: , �1�Hospitai Sueet P.o.eox$as C�unty Fil� Number: nno��i►� Nc 2�028 Date: ! / . . . . . . . . � . . Qinch Drawin� Dr� Type: Qperation Permit Scale: . ON�c�c = :ft. O _ � � , � � �� -- r- . _ � �` ~- �' . . � �. _�_._. . �� .� W -��- , - - ` s ; _ I I ' 1 _ _ �. � � �� , -�,G�'f� � : � 1 I � � _ � � i � � °' �" , .... „ � �,_ � � + � .'�'....'`'� `��... __ � � ��..�. :� .�...��. ��,.��... _ �.� �.. �...�w. . . ....��$ ,,.. ��....�.��...� � � �. � � r, _.�: .-= l � ..I�.� � �_ � � � _ _ � t �,,,,� � ` � � � i . � I _ � � � , _ � _ �,- . --�--- ��,�: �`` �.�.. �..._..;..�____:� .. � ____._.� � '�� . ��. �._.�.. :,� �; . __..___ .� �._.. .�� _ _ � , � � _ �� . . � _...�... _ � For Office Use Onlv • CONSTRUCTION �• . AUTHORIZATION *CDP File Number �s�72s- � ' �.•:�="F'� Davie County Health Department County ID Number: � � 210 Hospital Street Evaluated For. REPAIR .�,�„o,. P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax: 336-753-1680 � 1 / 1 5 / a 0 a 0 Applicant: Jim Cartner/Rental Property Property Owner: Jim Cartner/Rental Property � Address: 459 Shady Knoll Lane Address: 1908 Cross Pond Drive City: Mocksville City: Colfax State/Zip: NC 27028 State/Zip: NC 27239 Phone#: �336)817-6573 Phone#: (336)817-6573 Propertv Location & Site Information Address/Road#: Subdivision: Phase: Lot: 459 Shady Knoll Lane Mocksville NC 27028 Directions Structure: SINGLE FAMILY Down by South Davie, Jericho Ch Rd.turns into Davie Academy, stay to right on Davie Academy, Shady Knoll #of Bedrooms: 3 on right. #of People: "W8t@�SUppIY: EXISTING WELL SVstem Specifications Minimum Trench Depth: a 4 Site Classification: Prov�sionairy suitabte Inches Minimum Soil Cover: Saprolite System? O Yes �No 1 a Inches Design Flow: 3 6 0 � Maximum Trench Depth: 3 6 Inches Soil Application Rate: � , a � .rJ Maximum Soil Cover: a 4 Inches "System Classification/Description: *DIStfIbUtI0f1 Typ@: GRAVITY-PARALLEL(eq.d-box) TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: Gallons 'Proposed System: 2s°�o Re�ucTioN 1-Piece: �Yes 0 No Pump Required: QYes �No Q May Be Required Nitrification Field 1 3 0 9 Sq.ft. Pump Tank: Gallons No. Drain Lines 3 1-Piece: OYes �No Total Trench Length: 3 a � ft GPM--vs— ft. TDH Trench Spacing: _ �Inches O.C. _ g Feet O.C. Dosing Volume: Gallons Trench Width: _ 3 �Inches Feet Grease Trap: Gallons Aggregate Depth: inches Pre-Treatment: O NSF OTS-I O TS-II Septic Tank Installer Grade Level Required: O I O I I O III O IV Page 1 of 3 . CDP File Number 187728 - 1 County ID Number: • , ❑ Open Pump System Sheef .�� Repair System Required:OYeS O No �No, but has Available Space Repair System Inches O. . Trench Spacing: � *Site Classification: — O Feet O.C. Trench Width: Inches Design Flow: — Feet Aggregate Depth: Soil Application Rate: inches � . Minimum Trench Depth: "System Classification/Description: Inches Minimum Soil Cover: Inches Maximum Trench Depth: "'Proposed System: Inches Maximum Soil Cover: Nitrification Field Inches Sq.ft. No. Drain Lines ''Distribution Type: Total Trench Length: ft Pump Required: OYes Q No Q 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. Reme��9 750 *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. Rama�;�9 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 130A-336(b)).If the Installation has not been completed during the period of validity of the Construction Permit,the lnformation 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(g)).The person owntng or controlling the system shall be responsible for assuring compliance with the laws,rules,and permit conditlons regarding system location,installation,operation,maintenance,monitoring,reporting and repair (1938(b)). Applicant/Legal Reps. Signature Required? O Yes 0 NO ApplicanULegal Reps. SignaturP� Date: � � "ISSUed By: 2�40-Nations,Robert Date of Issue: 0 1 / 1 5 / a 0 1 5 Authorized State Agent: ��` `�� Malfunction Log OYes �; �= �Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 • • . CONSTRUCTION AUTHORIZATION . ;� Davie County Health Department CDP File Number: 187728 - 1 210 Hospital Street P.O.Box 848 County File Number: Mocksville rvc 2�o2s Date: 0 1 / 1 5 / a 0 1 5 �Inch Drawing Drawing Type: Construction Authorization Scale: , , OO N��ck = , ,ft. ,—,-- I I i I , , � ; � _ �- � � ; I .� .�.� �o,r� � I S� i � _ �- , --,------ {--- ------- -- — �� , � � ----------- _ _----{ � c G� � , i �� 'r _ �'�(P� � ._ � � � ' � ' i �i�-� ��' ��,.i'�j��' j � � - j � I � , , ' T � _-- -- _ .- -�-- _ . __ � __ . , 1___ i � ��r--_ I _� _ ) �, i 1 � � i i ; ' � I I , I ��.� � , I .d4� � � _ l � ,� t �^� � � � , � ; � � ---- ---�- ------ ----------- — � � - ---�c-----� � - --- r----� ----�.----;--------- ------- ; �-------- - � _ --= � �� . 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'� � _�►s.�u� �l� w ,�'�G, ,`.�17 C��• lv r � �,� « l d � d �� S� '��a -- - ; -T- _.�C ._� s , �- � rt�-� -t--;� _ ; I -c �0 7`�-�J s --e �c s d �;s , i I i � -I -- - � -- ------ ; : --- _---� f ----_ __ _-_; ___-:_____ ---�— ---------- --- — -_I --- - t---- ; ; � 1-- �_f � g_ _� : ; , _� ;_ ; .. _3_ Y _ � � ; � , ' � � � _ � � : . ! ; � _____ __�_____ ___________ __ ____ ____ -_ _ � : __ . _________ ______ � _ ____ _ _ ___ .. _ __ ___ Page 3 of 3 P1 P2