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104 Starlight Ln OPERATION PERMIT or HiceuseunlV ,. Davie County Health Department *CDP File Number 136841 -1 - 210 36841 -1210 Hospital Street 02000001001 P.O. Box 848 County ID Number, Mocksville NC 27028 Evaluated For. NEW Phone:336-753-6780 Fax:336-753-1680 Township: Applicant: Charles Wyatt r operty Owner: Charles Wyatt Address: 104 Starlight Lane ddress: . 104 Starlight Lane Cty: Mocksville ty: Mocksville State0l): NC 27028 'StaterZip: NC 27028 Phone#: Phone#: Pro a Location & Site Information Address/Road #: Subdivision: Phase: Lot: 104 Starlight Lane Mocksville NC 27028 Directions structure: SINGLE FAMILY hwy 601 N. left on Liberty Chruch Rd. then Left on Bear Creek Rd. Right on Ben Anderson Rd. Right on #of Bedrooms: 3 Shoffner, then to Starlight. Lane #of People: *Water Supply: NIA *IP Issued by 21ao-Nations,Robert 'System Classification/Description: TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPO OR LESS) *CA issued by: 2140-Nations,Robert Saprolite System? OYes ®No Design Flow: - 3 6 0 'Distribution Type: GRAVITY-SERIAL Pump Required? OYes @No Soil Application Rate: 0 - a 7 5 *Pre Treatment: Drain field Nitrification Field 1 3 0 9 SQ.ft- *System Type: SIDIFUSER STANDARD No. Drain Lines 3 Instauer: TimAbee Total Trench Length: 3 2 7 It. Certification#: 1011 Trench Spacing: _ 9 Inches O.C. s Feet O.C. 'EH S: 2140-Nations.Robert Trench Width: _ 3 Olnches (*)Feet Date: 0 5 / 1 9 / 2 0 1 4 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. 4 Inches Approval,Status Maximum Trench Depth: 3 6 ® Appr`oved O Disapproved Inches Maximum Soil Cover: a 4 Inches CDP File Number 136841 - 1 County ID Number: 02000001001 Septic Tank Manufacturer: Shoat- Lat. STB: 760 Long: Gallons: 1000 Installer rim Atxe Certification#: 1101 Date: to l / a 4 / a0 1 4 *EHS: 2140-Nations,Robed 'Filter Brand: POLYLOK PL-122 With Pipe Adapter ST Marker. ❑ Yes 2 No Date: _0 5 / 1 9 / x 0 1 4 � APP�at Status Reinforced Tank: ❑ Yes ® No A` roved❑ Dlsa roved 1 Piece Tank: El Yes n No �❑ PP pP Pump Tank Manufacturer Installer. PT: Certification#: Gallons: "EHS: Date: Date: RiserSealed ❑ Yes ❑ No - RiserHebht: ❑ Yes ❑ No (Min.6 in.) Approval Status Reinforced Tank: ❑ Yes ❑ No p Approved❑ Disapprovetl 1 Piece Tank: ❑ Yes ❑ No Supply line CPoe Size: inch diameter Installer. Pipe Length: feet Certification#: *Schedule: "`EHS: Pressure Rated ❑ Yes ❑ No Dater Approved fittings ❑ Yes ❑ No Approval Status © Approved❑ Disapprovetl Pump Requirement Pump Type: Installer. Dosing Volume: — Gal Certification#: Draw Down: Inches *EHS: 'Chau: Date: Valves Accessible ❑ Yes ❑ NO Flow Adjustment Valve ❑ Yes ❑ No Check-valve ❑ Yes ❑ No gpprovaCStatus{ PVC unions ❑ Yes ❑ No ❑ Approved❑ Disapprovetl , Vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ Yes ❑ NO CDP File Number 136841 - 1 County ID Number: C2000001001 Electric Equipment NEMA4XBox 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 ❑ Yes ❑ No ❑ Approved❑ Disapproved, Alarm visible ❑ Yes ❑ NO ; 2140-Nations,Robert 'Operation Permit completed by, Authorized State Agent: Date of Issue: 0 5 / 1 9 / 2 0 1 4 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 as conditions of the Improvement Permit and Construction Authorization.This property is served by a TYPE It A. sewage septic system. Rule.1961 requires that a Type TYPE II A. septic system meet the following criteria: Minimum System Review By The Local Health Department: WA Management Entity: OWNER - Minimum System Inspection/Maintenance Frequency ByCertified Operator: WA 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 entity with a certified operator or a private certified operator forthe 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 ownerand 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. @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** ` OPERATION PERMIT 13684-1 - 1 Davie County Hearth Department CDP File Number: 210 Hospital Street 02000001001 P.O.Bax MCounty File Number: Mocksvilre NC 27028 Date: J O Inch Scale: Drawing Drawing Type: Operation Permit . O A k ft. f f � i CONSTRUCTION For office use only 7 AUTHORIZATION 'CDP File Number 136841 -1 •= Davie County Health Department 02000001001 ty P County ID Number. t 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 / 3 1 / .2 0 1 9 Applicant: Charles Wyatt Property Owner. Charles Wyatt Address: 104 Starlight Lane Address: 104 Starlight Lane City: Mocksville City: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 Phone#: Phone M Property Location &Site Information Address/Road#: Subdivision: Phase: Lot: 104 Starlight Lane Mocksville NC 27028 Directions Structure: SINGLE FAMILY hwy 601 N. left on Liberty Chruch Rd.then Left on Bear Creek Rd. Right on Ben Anderson Rd. Right on Shoffner, #of Bedrooms: 3 then to Starlight. Lane #of People: *Water Supply: N/A System Specifications Minimum Trench Depth: 01 4 Site Classification: Provisionally suitable Inches Minimum Soil Cover. Saprolite System? O Yes (,9 No 1 a Inches Design Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 . 22 7 5 Maximum Soil Cover. a 4 Inches `System Classification/Description: *Distribution Type: GRAVITY-SERIAL TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons *Proposed System: 259/6 REDUCTION 1-Piece: O Yes ®No Pump Required: O Yes ®No O May Be Required Nitrification Field 1 3 0 9 Sq.ft. Pump Tank: Gallons No. Drain Lines 3 1-Piece: OYes ONo Total Trench Length: 3 a 7 ft GPM—vs— ft. TDH Trench Spacing: Inches O.C. — 9 Feet O.C. Dosing Volume: Gallons Trench Width: 3 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 01V Page 1 of 3 CDP-File Number 136841 - 1 County ID Number: 02000001001 ❑ Open Pump System Sheet Repair System Required:0 Yes O No ONO, but has Available Space rDesignFlow: System Trench Spacing: 9 Inches O.C. ification: Provisionally suitable — Feet O.C. Trench Width: O Inches 3 6 0 — 3 ®Feet Soil Application Rate: Oass Aggregate Depth: inches . Minimum Trench Depth: a 4, Inches *System Classification/Description: TYPE 111 B.SYSTEM W/SINGLE EFFLUENT PUMP Minimum Soil Cover: 1 a Inches *Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Nitrification Field 1 3 0 9 Sq.ft. Maximum Soil Cover. a 4 Inches No. Drain Lines 3 *Distribution Type: GRAVITY-SERIAL Total Trench Length: 3 a 7 ft Pump Required: OYes ®No OMay Be Required Pre Treatment: O NSF OTS-I OTS-II *Site Modifications rhwwctm No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. 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. R�� 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 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: *Issued By: 2140-Nations obert Date of Issue: 0 3 / 3 1 / a 0 1—f� 4 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: 210 Hospital Street County File Number: c2000001001 P.O.Box 848 Mocksville NC 27028 Date: 03 / 31 / 2014 O Inch Drawing Drawing Type: onstruction Auth ation Scale: , O Block - ft. D N/A r A A% 3 Co- Gy Page 3 of 3 P1 P2 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: P.O.Box 848 02000001001 Mocksville NC 27028 County File Number: Date: A:3 / 3 1 / . 0 14 Click below to import an image from an external location: Drawing Type:Construction Authorization Page 3 of 3 P1 P2 CONSTRUCTION For office Use only AUTHORIZATION *CDP File Number 136841 -1 Davie County Health Department County ID Number:02000001001 f 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 / 3 1 / 2 0 1 9 Applicant: Charles Wyatt Property Owner. Charles Wyatt Address: 104 Starlight Lane Address: 104 Starlight Lane City: Mocksville City: Mocksville StatefZip: NC 27028 StatefZip: NC 27028 Phone#: Phone#: Property Location & Site Information rAddress/Road #: Subdivision: Phase: Lot: ght Lane e NC 27028 Directions Structure: SINGLE FAMILY hwy 601 N. left on Liberty Chruch Rd. then Left on Bear Creek Rd. Right on Ben Anderson Rd. Right on Shoffner, #of Bedrooms: 3 then to Starlight. Lane #of People: *Water Supply: NIA System Specifications Minimum Trench Depth: a 4 Site Classification: Provisionally Suitable 7nchesMinimum Soil Cover. 1 a Saprolite System? OYes C}NoDesign Flow: 3 6 0 Maximum Trench Depth: 3 6 Soil Application Rate: 0 2 7 5 Maximum Soil Cover: a 4 Inches 'System Class ification/Description: 'Distribution Type: GRAVITY-SERIAL TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons 'Proposed System: 25%REDUCTION 1-Piece: OYes QNo Pump Required: OYes @No OMay Be Required Nitrification Field 1 3 0 9 Sq.ft. Pump Tank: Gallons No. Drain Lines 3 1-Piece: OYes ONo Total Trench Length: 3 a 7 ft GPM vs— ft. TDH Trench Spacing: _ 9 2Inches O.C. Dosing Volume: _ Gallons Feet O.C. Trench Width: _ @Inches 3 Feet Grease Trap: Gallons Aggregate Depth: inches PreTreatment: ONSF OTS-1 OTS-II Septic Tank Installer Grade Level Required: 01011 O III 01V Pagel of 3 CDP File Number 136841 - 1 County ID Number: C2000001001 ❑ Open Pump System Sheet Repair System Required:Wes ONO ONO, but has Available Space rDesign System Trench Spacing: ( Inches O. . ification: Provisionally Suitable — 9 # Feet O.C. Trench Width: Q Inches w: 3 6 0 — 3 Feet Soil Application Rate: 0 a 7 s Aggregate Depth: inches Minimum Trench Depth: a 4 Inches *System Classification/Description: TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Minimum Soil Cover. 1 a Inches 'Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Nitrification Field 1 3 0 9 Sq.ft. Maximum Soil Cover: a 4 Inches No. Drain Lines 3 *Distribution Type: GRAVITY-SERIAL Total Trench Length: 3 a 7 Pump Required: OYes �No OMay, equired Pre Treatment: ONSF OTS-1 :BeOTS-II `Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. 7! *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. 2( This Authorization for Wastewater System Construction shall bevalid 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"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: *Issued By: 2140-Nations, Obert Date of Issue: . 0 3 3 1 2 0 1 4 Authorized State Agent: Malfunction Log Oyes OHand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 • CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number. ' 210 Hospital Street County File Number: C2000001001 P.O.Box 848 Mocksville NC 27028 Date: 0 3 / 3 1 / 2 0 1 4 Olnch Dira�vin� Drawing Type: onstruction Auth ' ation Scale: , OBI!ock QN/A FTTT-1171­ I I � Q -- 1 I r o sl r4-- I ► - �___I I I _ _ _ _�_I. Paae 3 of 3 .__... A ' APPL C I T FOR SITE EVALUATIONAWROVEMENT PERMIT & ATC Davie County Environmental Health PAID I� P.O.Box 848/210 Hospital Street Data. 3, Mocksville,NC 27028 1 (336)753-6780/Fax(336)753-1680 s Application For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) 14oth Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name e-S V lA la±+ Contact Person Address IQ�L -S-ba r11�+ Ln . Home Phone City/State/ZIP�� Vii- IVIG c 0aY Business Phone Email Email: Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site,Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name r Phone Number Owner's Address City/State/Zip Property Address City Lot Size . Q"1 Tax PIN# Subdivision Name(if applicable) Section/Lot# Directions To Site: If the answer to any of the following questions is"Yes",supportin documentation must be attached: Are there any existing wastewater systems on the site? Yes No Does the site contain jurisdictional wetlands? Yes /No Are there any easements or right-of-ways on the site? Yes VNo Is the site subject to approval by another public agency? Yes ✓No i Will wastewater other than domestic sewage be generated? Yes *O IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms -?> #Bathrooms_6'� Garden Tub/Whirlpool ❑Yes R115— Basement: ❑Yes o Basement Plumbing: ❑Yes 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 r Type system requested: ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other ` L�a da�vi'e CouAy,NC Tax Parcel Report Thursday,March 13,2014 32 rC A i Z Z rn x' Apo �f 6 '104 CO Ln X233 -► 236 C15 i f j\� 40 m / f� !/J/ 100 ft 120 /I v N i WARNING:THIS IS NOT A SURVEY Parcel information' "., ,.. ... Parcel Number. C20000001001 Township: Clarksville NCPIN Number. 5802772458 Municipality: Account Number. 82526590 Census Tract: 37059-801 Listed Owner 1: WYATT CHARLES E SR Voting Precinct: CLARKSVILLE Mailing Address 1: 104 STARLIGHT LANE Planning Jurisdiction: Davie County City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-A State: NC Zoning Overlay: Zip Code: 27028-0000 Voluntary Ag.District: No Legal Description: 1 AC OFF SHOFFNER RD Fire Response District: SHEFFIELD-CAL.AHALN Assessed Acreage: 0.97 Elementary School Zone: WILLIAM R DAVIE Deed Date: 6/2006 Middle School Zone: NORTH DAVIE Deed Book/Page: 006670538 Soil Types: MnC2,MnB2 . Plat Book: Flood Zone: x Plat Page: Watershed Overlay: Building Value: 0.00 Outbuilding&Extra 1340.00 Freatures Value: Land Value: 13730.00 Total Market Value: 15070.00 Total Assessed Value: 15070.00 All data is provided as is without warranty or guarantee of any kind either expressed or implied Including but not limited to the � Davie County,NC implied warranties of merchantability or fitness for a particular use.All users of Davie County's GIS website shall hold o�St hprmla§D fht3—owy-of Dovi@i NQrfh-Arptng,ifs ADPT i eenMuftfln?§;FPrft—OPM-or PMA-oygm"m€nyPnd p)I claim§Pr causes of action due to or arising out of the use or inability to use the GIS data provided by this website. d 310 n 1 Ig5 ,� ss ail" ' r � 1 V wanfs A., nd I n s bazj f understa d that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or stz! a house/fa-1 do proposed well location and the location of any other amenities. Property owner's or owner's legal representative signature Site Revisit Charge Date(s): _ Client Notification Date: Date EHS: i DAVIE COUNTY HEALTH DEPARTMENT I I Environmental Health Section I Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION �3(���{1 CZ ooboo=v!-oo1 Account #: Tax PIN/EH#: Billed To: n f, I �/� L� Subdivision Info: Reference Name: U 6 W7T Location/Address: /a 1� S'( r)I- Proposed Facility: Property Size: ^�1 Date Evalua ed: New Ho"e' J Water Supply: On-Site Well Community Public Evaluation By: ; Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 1 7 Landscape position i Slope % i HORIZON I DEPTH i Texture group Consistence i Structure l Mineralogy HORIZON H DEPTH 1 Texture group Consistence Structure ! Mineralogy i J HORIZON III DEPTH ! Texture group . Consistence J' Structure 1 Mineralogy I .HORIZON IV DEPTH f Texture groupi Consistence Structure i MineralogyI SOIL WETNESS i RESTRICTIVE HORIZON i SAPROLITE I CLASSIFICATION I LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: i LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: LEGEND 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 i 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 i SIC-Silty clay C-Clay CONSISTENCE Moist VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm 3y-d i 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-Subangulai blocky PL-Platy PR-Prismatic 1 Mineralogy 1:1,2:1,Mixed 1 Horizon depth-In inches ! Depth of fill-In inches J 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 accentance rate- ual/dav/ft2