153 Shore LnOPERATION PERMIT
Davie County Health Department
° ¢ 210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant:
Jody Shore
Address:
152 Shore Lane
City:
Yadkinville
State/Zip:
NC 27055
Phone #:
(704) 500-6272
Property Loca
Address/Road #: Subdivision:
153 Shore Lane
Yadkinville NC 27055
Structure: SINGLE FAMILY
# of Bedrooms:
# of People:
*Water Supply: N/A
*IP Issued by:
*CA Issued by: 2399 - Eldridge, Tiffany
Design Flow: 3 6 0
Soil Application Rate: 0 a 5
Nitrification Field
No. Drain Lines
Total Trench Length
Trench Spacing:
Trench Width:
Aggregate Depth:
*CDP File Number 235886 - 1
5803397582
County ID Number:
Evaluated For: REPAIR
�ownship:
/Property Owner:
Jody Shore
Address:
152 Shore Lane
City:
Yadkinville
State/Zip:
NC
Phone #:
(704) 500-6272
ion & Site Information
27055
Phase: Lot:
Hwy 601 North , left on Liberty Church Rd. Shore
Lane on Left.
*System Classification/Description:
TYPE III G. OTHER NON-CONV. TRENCH SYSTEMS
Saprolite System? '.,Yes X, No
*Distribution Type: GRAVITY -SERIAL Pump Required?
0 Yes X No
*Pre -Treatment:
Drain field
1 4 4 0 Sq. ft.
4
360ft.
9 0Inches O.C.
(9 Feet O.C.
3 Olnches
(9 Feet
inches
Minimum Trench Depth:
a
4
Inches
Minimum Soil Cover:
1
a
Inches
Maximum Trench Depth:
3
6
Inches
Maximum Soil Cover:
)
4
Inches
Page 1 of 4
*System Type: INFILTRATOR QUICK STANDARD
Installer: Jody Grimes
Certification #: 5170
*EHS: 2399 - Eldridge, Tiffany
Date: 0 4/ 1 3/.1 0 1 7
Approval Status
❑ Approved ❑ Disapproved
CDP File Number 235886 - 1
County ID Number: 5803397582
Manufacturer:
Pump Type:
PT:
se tic i anK
inch diameter
Manufacturer:
Riser Sealed
❑ Yes
Lat.
❑ Yes
Reinforced Tank:
❑ Yes
\ 1 Piece Tank:
❑ Yes
Long:
❑ No
STB:
Approved fittings ❑ Yes
❑ No
*EHS:
Approval Status
Gallons:
*Chain:
❑
Approved ❑ Disapproved
Installer:
Date:
Certification #:
Date:
*EHS:
Valves Accessible
*Filter Brand:
Yes
❑
No
Flow Adjustment Valve
❑
Yes
❑
No
ST Marker:
❑
Yes
❑ NO
Date:
❑
Reinforced Tank:
❑
Yes
❑ NO
PVC unions
Approval Status
Yes
❑
No
❑
El
Approved El Disapproved
1 Piece Tank:
El
Yes
El NO
NO
Manufacturer:
Pump Type:
PT:
Gallons:
inch diameter
Date:
Riser Sealed
❑ Yes
Riser Height:
❑ Yes
Reinforced Tank:
❑ Yes
\ 1 Piece Tank:
❑ Yes
❑ No
❑ No (Min. 6 in.)
❑ No
❑ No
Pump Tank
Installer:
Certification #:
*EHS:
Date:
Approval Status
❑ Approved ❑ Disapproved
/
Pump Type:
Supply Line
Pipe Size:
inch diameter
Installer:
Pipe Length:
feet
Certification #:
*Schedule:
*EHS:
Pressure Rated ❑ Yes
❑ No
Date:
Approved fittings ❑ Yes
❑ No
*EHS:
Approval Status
*Chain:
❑
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
Page 2 of 4
CDP File Number 235886 - 1
County ID Number: 5803397582
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 Status
Alarm Audible
El
Yes
ElNo
❑Approved ❑ Disapproved
Alarm Visible
ElYes
❑
NO
2399 - Eldridge, Tiffany
*Operation Permit completed by:
Authorized State Agent: Date of Issue: 0 4/ 1 3/.1 0 1 7
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 TYPE 111 G. sewage septic system.
Rule .1961 requires that a Type TYPE 111 G. septic system meet the following criteria:
Minimum System Review By The Local Health Department: N/A
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency By Certified Operator:
N/A
Reporting Frequency By Certified Operator: N/A
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.
9 Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 3of4
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Operation Permit
CDP File Number: 23586 - 1
County File Number: 5803397582
Date: / /
0 Inch
Scale: O Block
0 N/A
1
W-1
•
Q ,
< sty
F
3
Page 4 of 4 P1 P2 P3
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC
CDP File Number:
27028 County File Number:
Date:. . /
Click below to import an image from an external location: Drawing Type: Operation Permit
5803397582
Page 4 of 4 P1 P2 P3
Drain Field: System Final Inspection Log:
Characters
Remaining
4000
Septic Tank:
Pump Tank:
Supply Line:
Pump Requirements:
Electrical Equipment:
P1 P2 P3
Characters
Remaining
4000
Characters
Remaining
4000
Characters
Remaining
4000
Characters
Remaining
4000
Characters
Remaining
4000