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102 Star Magnolia Ave Lot 22 ' OPERATION PERMIT EEvaluated ice se n v s fes. Davie County Health Department Number, 201976-1 210 Hospital Street 5880510323 P.O.Box 848 umber. Mocksville NC 27028 or. NEWPhone:336-753-6780 Fax:336-753-1680 . Applicant: Penny Stroupe Property owner. RPS Custom Builders LLC Address: PO Box 277 Address: PO Box 277 city: . Mocksville City: Mocksville State/Zip: NC 27028 StatefZip: NC 27028 Phone#: (336)816-1293 Phone#: (336) 816-1293 Property Location & Site Information C:Address/Road#: Subdivision: Magnolia Acres Phase: 1 Lot: 22 102 Star Magnolia Ave Advance NC 27006 Directions 1-40 East to Exit 180, turn right on Hwy 801. Turn Lefl structure SINGLE FAMILY on Peoples Creek Rd. left onto Magnolia Acres #of Bedrooms: 3 - #of People: *Water supply: PUBLIC *IPlssued by. 21.10-Nalmns,Robert *System Classification/Description: TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140-Nations,Robert Saprolite System? OYes QNo Design Flow: 3 6 0 GRAVITY-SERIAL Pump Required? Distribution7ype: QYes INo Soil Application Rate: 0 a ? 5 *Pre Treatment: Drain field rNonDratin caon Field 1 3 , 0 9 Sq.ft. *System Type: INFILTRATOR QUICK 4 STANDARD Lines 4 Installer: Jamie Barnes Total Trench Length: 3 a 8 ft. Certification#: 1018 Trench Spacing: 9 _ ()Inches t O.C. 'EHS: 2140•Nations Robert Trench Width: 3Inches gFeet Date: 0 8 / 3 1 / .1 0 1 6 Aggregate Depth: inches i Minimum Trench Depth: 3 6 Inches Minimum Soil Cover, 2 4 Inches -Approval status Maximum Trench Depth: 3 6 ® Approved Cl Disapproved Inches Maximum Soil Cover: 2 4 Inches CDP File Number 201976 - 1 County ID Number: 5880510323 Septic Tank Manufacturer Shoaf Let. STB: 760 Long: Gallons: 1000 Installer Jamie Barnes Certification#: 1018 Date: 0 7 / 1 a l x 0 1 6 ` *ENS: 2140-Nations"Robert *Filter Brand: POLYLOK Dual PL-122 With Pipe Adapter ST Marker. El Yes ® No Date: . 0 . 8 � 3 1 / a 0 1 6 Reinforced Tank; ❑ Yes No Approval Status 1 Piece Tank: ❑ Yes D NO ID ApProvod�❑ Disapproved Pump Tank Manufacturer, Installer PT: Certification#: Gallons: *EHS: Date: Date: RiserSealed ❑ Yes ❑ No RiserNeght: [:1 Yes ❑ NO (Min.6 in.) r :; Approval Status Reinforced Tank: ❑ Yes ❑ No O Apprave�d❑ Disapproves! 1 Piece Tank: ❑ Yes ❑ NO . _. Supply Line Pipe Size: inch diameter Installer. Pipe Length: feet Certification#: *Schedule: 'EHS: Pressure Rated ❑ Yes ❑ Na Date: Approved fittings ❑ Yes ❑ NO Approval Status £D Approired❑ Disapprover Pump RequirqMent 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 v ❑ Approved❑ Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole El Yes ❑ NO CDP File Number 201976 - 1 County ID Number: 5880510323 Electric Equipment NEMA4XBoxorEquivalent ❑ Yes ❑ No Installer: Box 12 inches Above Grade E) 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❑ disapproved . Alarm visible ❑ Yes ❑ No 2140•Nations,Robert 'Operation Permit completed by: Authorized State Agen Date of Issue: 0 8 / 3 1 / 2 0 1 6 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 11 A sewage septic system. Rule.1961 requires that a Type TYPE n A. septic system meet the following criteria: Minimum System Review ByThe Local Health Department: NIA 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 homelbusiness owner must maintain a valid contract with a public management entitywith a certified operatoror a private certified operator forthe life ofthe 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 by 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. GHand Drawing Olmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT 201976 - 1 Davie County Health Department CDP File Number: 210 Hospital Street 5880510323 P.O.sox 848 County File Number: Mocksville NC 27028 Date: /.,..J...�,J J 0Inch Drativing Drawing Type: Operation Permit / Scale: QN A k G 'G� Q • { A-1 It Irf I I I _a I • GONSTRUCTION For office Use only AUTHORIZATION 'COP File Number 201976-1 Davie CountyHealth Department 5880510323 p County ID Number. 210 Hospital Street Evaluated For. NEW .� ,,. P.O.Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone:336-753-6780 Fax:336-753-1680 0 3 / a 3 / a 0 a 1 Applicant: Penny Stroupe Property Owner: RPS Custom Builders LLC Address: PO Box 277 Address: PO Box 277 City: Mocksville City: Mocksville State/Zip: NC 27028 StatefZip: NC 27028 Phone#: (336)816-1293 Phone#: (336)816-1293 Property Location & Site Information FAddress/Road#: Subdivision: Magnolia Acres Phase: 1 Lot: 22 tar Magnolia Ave nce NC 27006 Directions Structure: SINGLE FAMILY. 1-40 East to Exit 180, tum right on Hwy 801.Turn Left on - - - Peoples Creek Rd. left onto Magnolia Acres #of Bedrooms: 3 #of People: "Water Supply: PUBLIC - System Specifications Minimum Trench Depth: a � rSdessification: Provisionally Suitable Inches Minimum Soil Cover. 1 a System? QYes VNo Inches glow: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 - a 7 5 Maximum Soil Cover a 4 Inches 'System Classification/Description: 'Distribution Type: TYPE If A.COM/SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 _ Gallons 'Proposed System: 25%u REDUCTION 1-Piece: QYes (S)No Pump Required: QYes ®No QMay Be Required Nitrification Field 1 3 0 9 Sq. ft. Pump Tank: Gallons No. Drain Lines 3 1-Piece: QYes QNo Total Trench Length: 3 a 7 ft GPM—vs— ft. TDH Trench Spacing: — 9 @Inches t 0 CC. Dosing Volume: Gallons Trench Width: 3 Inches Aggregate Depth: @Feet Grease Trap: Gallons _ _ inches Pre Treatment: O N S F OTS-I OTS-I I Septic Tank InstallerGrade Level Required: OI OII O III OIV Donn I of Z CDP File Number 201976 - 1 County ID Number. 80510323 , ❑ open Pump System Sheet Repair System Required:@Yes ONo ONO, but has Available Space rDnesign System Trench Spacing: 9 Olnches 0. ification: Provisionally Suitable — e Feet O.C. Trench Width: Inches w: 3 6 0 — 3 Feet Aggregate Depth: Soil Application Rate: 0 a a 5 inches Minimum Trench Depth: a *System Classification/Description: Inches TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover 1 a Inches *Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: a 4 Nitrification Field 1 6 0 0 Sq.ft. Inches No. Drain Lines 4 *Distribution Type: GRAVITY-SERIAL ,Total Trench Length: 4 0 0 Pump Required: QYes ®No OMay Be Required 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. r *Permit Conditions The issuance of this permit bythe Health Department in no wayguarantees 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 fora 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(g)).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:- _ 2140-Nations,Ro 0 3 / a 3 / a 0 1 6 *Issued By: Date of Issue: . Authorized State Age Malfunction Log Oyes F; @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number: 210 Hospital Street 5880510323 P.O.Box 848 County File Number: Mocksville NC 27028 Date: 0 3 / 23 1 2 0 1 6 Q Inch Drawing Drawing Type: Construction Authorization Scale: QBlock Q N/A �l /-�- -q--{-y GW I HI I I I I 15 } P or l 11My !0..0 1 I 1 L I I �� � `• I ��_ Imo. I �b � CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: P.O.Box 848 5880510323 Mocksville NC 27028 County File Number. Date: .0 .3 / � 3 l � 016 S >'2 (-1 CA �� Cit/✓tom S . . _ Click below to Import an image from an external location: rawirtg ype:Construction Authorization a a ©. � d fj 59.k� �c h 6A T r - IMPROVEMENT PERMIT ForofficeUse Only *CDP File Number 201976-1 Davie County Health Department 210 Hospital Street County ID Number.5880510323 P.O. Box 848 Evaluated For. NEW Mocksville NC 27028 Township: Phone:336-753-6780 Fax:336-753-1680 PERMIT VALIo UNTIL: 3/23/2021 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: Penny Stroupe Property owner: RPS Custom Builders LLC Address: PO Box 277 Address: PO Box 277 Cty: Mocksville Cty: Mocksville StatefZip: NC 27028 State/Zip: NC 27028 Phone#: (336)816-1293 Phone#: (336)816-1293 Prol2erty Location & Site Information r. AdfivancEeRoressad#: Subdivision: Magnolia Acres Phase: 1 Lot: 22 2 Star Magnolia Ave NC 27006 Directions Structure: SINGLE FAMILY- - 1-40 East to Exit 180, turn right on Hwy 801. Turn Lefi #of Bedrooms: 3 on Peoples Creek Rd. left onto Magnolia Acres #of People: *Water Supply: PUBLIC System Specifications nitial System *Sne Classifiication: Provisionally Suitable Minimum Trench Depth: 2 4 Inches Saprolite System? OYes Q No Maximum Trench Depth: 3 6 Inches Design Flow: 3 6 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 0 2 7 5 1-Piece: OYes @No `J Pump Required: OYes QNo OMay Be Required *System Classification/Description: TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons LESS) *Proposed System: 25%REDUCTION 1-Piece: OYes O N o Repair System Required:@Yes ONo ONO, but has Available Space Repair System *Site Classification: Provisionally Suitable Minimum Trench Depth: a 4 Inches Soil Application Rate: 0 2 2 5 Maximum Trench Depth: 3 6 Inches u *System Classification/Description: Pump Required: OYes Q No O Maybe Required TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System: 25%REDUCTION Pagel of 3 CDP File Number 201976 - 1 County ID Number 5880510323 . *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. j Site Plan The tnprovement Permit shall be valid for 6 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 the facility and appurtenances,the site forthe proposed Wastewater system,and the location of water supplies and surface waters). 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 or 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 time 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 aMcleL This permit is subject to revocation if the site plan,plat.or Intended use changes(NCGS 130A335(j).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)} Applicant/Legal Reps.Signature Required? Oyes ONO Applicant/Legal Reps.Signature; Date: 'Issued By: 2940-Nations,Robert Date of Issue: 0 3 / a 3 / a 0 1 6 Authorized State A e OValid without Expiration? g 0Create CA? UHand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 IMPROVEMENT PERMIT 201976 - 1 Davie County Health Department CDP File Number: 210 Hospital Street 5880510323 P.O.Box 848 County File Number: Mocksville NC 27028 Date: / 1 Olnch Drawing Drawing Type: Improvement Permit Scale: , Oslock ON/A w � —FI 1 % 117 A I i I i I I I I - - i d �C 0 V, I IMPROVEMENT PERMIT Davie County Health Department 210 Hospital Street CDP File Number: 201976 - 9 P.O.Box 848 5880510323 Mocksv�lle NC 27028 County File Number: Date: .03 / 23 / 2016 Click below to import an Image from an external location:Drawing Type: Improvement Permit N 9U 0'W 128.00' — — ------------------------- ------- ----------- j j I j I j I j jr__________30REAR YARD BUILDING SETBACK LINE I i i I I I I j I i i I I I j I i i I �I 9i i� Ig bj OI im Ib �jI I jo I I I -1 I I jPoRcw i ! 1 1/2 STORY FRAMED 2826 SQ.FT. I I I I if Sb" _I 41V i raRcw cPoRcw :cue G.ReGe 467 I I I I I I i i I I I I I I I L__________________________ _____J SO'FRONT YARD BUILDING SETBACK UNE I I I I I I I I I I L----•—•—•—•-------------90'0'--E 128.----00'------•— ------------J N STAR MAGNOLIA DRIVE LOT #22 MAGNOLIA ACRES ADVANCE, N.C. SCALE: I" = 20' VA? LI ON FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Davie County Environmental Health Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 Application For. J Site Evaluation/Improvement Permit C Authorization To Construct(ATC) &<th Type of Application: DNew System ❑Repair to Existing System :]Expansion/Modification of Existing System or Facility •••IhIPORTANT***THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICAN INFORMATION Name Contact Person Address Home Phone City/State/Z Business Phone Email Name n Permi A if Drer t th Above D Mailing Address City/State ip � PROPERTY INFORMATION *Date House/Facility Comers Flagged NOTE: A survey plat or site plan must accompany this application. Included:U Site Plan UPlat(to scale) (Permit is v ,, for 60 mont s with site plan,no ex 'ation yvith complete plat-) Owner's Name ne Number Owner's Address '17 A717 City State/ 'p �70,5C Property dre s rty Lot Size ' Tax PIN# l Subdivision Name(if applicable ection/Lot# �SF1 Directions To S' 10AZ -4n If the answer to any o ffik following questions is"Yes"supporti . g documentation must be attache Are there any existing wastewater systems on the site? _Yes %.M Does the site contain jurisdictional wetlands? _Yes _It?m Are there any easements or right-of-ways on the site? Yes No Is the site subject to approval by another public agency/ Yes No Will wastewater other than domestic sewage be generated? Yes No IF RESIDENCE FILL OUT THE BOX BELOW = . #People #Bedrooms ' #Bathrooms Garden Tub/Whirlpool I]Yes INo Basement: :]YesE.i Basement Plumbing: DYes ONc IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested: onventional ❑Accepted ❑Innovative ❑Altemative ❑Other Water Supply Type:"0. /City Water 0 New Well OExisting Well J Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?C Yes ❑No If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any perm' s or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the info ati submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative of the vie ounty Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. 1 unde tan hat I am responsible for a proper ide ification and labeling of property lines and corners and locating and flagging to in h /f ility to tion,pro oc io an the location of any other amenities. Pro r ow er' or own% lega rese a sig cure Site Revisit Charge ���� Date(s): Client Notification Date: Date EHS: Sign given I Yes ONo Account# O` Revised 11/06 Invoice# 3807 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION_LOTJ Soil/Site Evaluation APPLICANT'S NAME ���'l� �zP/' DATE EVALUATED PROPOSED FACILITY PROPERTY SIZE SUBDIVISIONC ROAD NAME J'L,m'�'��� Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L L Slope% °lv HORIZON I DEPTH —1 Texture groupC� L, Consistence Structure Mineralogy HORIZON II DEPTH Texture groupG G Consistence Structure Mineralogy - HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: a LONG-TERM ACCEPTANCE RATE: / OTHER(S)PRESENT: REMARKS: EGEND Landscape Position R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H.-Head slope Texture S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay , C-Clay CONSISTENCE oiA VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm et NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic Structure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogy 1:1,2:1,Mixed Notes Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface Saprolite-S(suitable),U(unsuitable) Soil wetness-Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification-S(suitable),PS(provisionally suitable),U(unsuitable) LTAR-Long-term acceptance rate-gal/day/ft2 DCHD(01.90)