824 Markland Rd Lot 8 OPERATION PERMIT FICDPFile
ce use v
Davie County Health Department umber 138034- 1
210 Hospital StreetP.O. Box 848mber:
Mocksville NC 27028 Evaluated For: NEW
Phone:336-753-6780 Fax:336-753-1680 Township:
Applicant: Morgan & Parker Builders rAd
erty Owner: Michael and Dana Zendory
Address: PO Box 770 ress:City: Clemmons y:
State/Zip: NC 27012 State/Zip:
Phone#: (336)998-9115 Phone#:
Property Location & Site Information
Address/Road #: Subdivision: Stonemoor Phase: Lot: 8
7
824 Markland Rd
Advance NC 27006 Directions
Structure: SINGLE FAMILY Hwy 64 east left on Hwy 801. approx 4 miles
#of Bedrooms: 4
Markland Rd. on left. Property on left
#of People:
'Water Supply: N/A
*IP Issued by: 21ao-Nations.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 2fNo
Design Flow: 4 8 0 'Distribution Type: GRAVITY-PARALLEL(eq.d-box) Pump Required?
OYes QNo
Soil Application Rate: 0 2 7 5 'Pre-Treatment:
Drain field
FNo.
on Field 1 7 4 5
Sq. ft. *System Type: INFILTRATOR QUICK 4 STANDARD
Lines a Installer: Billy Clayton
Total Trench Length: 4 3 6 ft. Certification#:
Trench Spacing: 9 Inches O.C.
Feet O.C. *EHS: 2140-Nations.Robert
Trench Width: 3 Inches
,* Feet Date: 1 1 / 1 0 / .2 0 1 4
Aggregate Depth: inches
Minimum Trench Depth: 3 6
Inches
Minimum Soil Cover. 2 4 Inches Approval Status
Maximum Trench Depth: 3 6 FS proved O Disapproved
Inches
Maximum Soil Cover: a 4
Inches
CDP File Number 138034 - 1 Septic Tank County ID Number:
Manufacturer. Shoaf Lat.
STB: 760 Long: ,
Gallons: 1000 Installer: Billy Clayton
Date:
0 6 1 1 4 J a 0 1 4 Certification-A"-:
*EHS: 2140-Nations,Robert
'Filter Brand:
Date: 1 1 J 1 0 J a 0 1 4
ST Marker: ❑ Yes C7 No -
Reinforced Tank: ❑ Yes 0 NO Approval Status
, Piece Tank: ❑ Yes O No E Approved❑ Disapproved
Pump Tank
Manufacturer. Installer:
PT: Certification-#:
Gallons: *EHS:
Date: J J Date: J J
Riser Sealed ❑ Yes ❑ NO
Riser Height: ❑ Yes ❑ No (Min.6in.) Approval Status
ed Tank: ElYes 1:1No ❑ Approved❑ Disapproved
foricce,
1 Tank: 0 Yes 0 NO
Supply Line
Pipe Size: inch diameter Installer:
Pipe Length: feet Certification#:
'Schedule: 'EHS:
Pressure Rated ❑ Yes ❑ No Date: J J
Approved fittings ❑ Yes ❑ NO Approval Status
11 Approved❑ Disapproved
Pump e
r
Pump Type: Installer:
sing Volume: — Gal Certification#:
Draw Down: Inches *EHS:
'Chain: Date: J J
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 0 No
CDP File Number 138034 - 1 County ID Number:
Electric Equipment
NEMA4X Box or Equivalent ❑ Yes El 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: f J
Approval Status
Alarm Audible ❑ Yes ElNo ❑ Approved❑ Disapproved
Alarm Visible E] Yes 11No
2140-Nations,Robert
'Operation Permit completed by:
Authorized State Agent: �— Date of Issue: 1 1 / 1 4 / 2 0 1 4
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 TY'E rl A. septic system meet the following criteria:
Minimum System Review By The Local Health Department: NIA
Management Entity: OWNER N
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 for a homelbusiness 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 V I 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 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.
QHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT 138034- 1
Davie County Health Department CDP File Number:
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: J J
O inch
Drawing Drawing Type: Operation Permit Scale: . OON/A k �
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CONSTRUCTION 0 P For office use Only
AUTHORIZATION *CDPFile Number 138034-1 . ,
Davie County Health Department P County ID Number:
" 210 Hospital Street Date: /
aluated For: NEW
P.O. Box 848 Received by:
•.a.:�• To
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 0- 5- / 0 6 / a 0 1 9
Applicant: Morgan&Parker Builders Property Owner: Michael and Dana Zendory
Address: PO Box 770 Address:
City: Clemmons City:
State/Zip: NC 27012 State/Zip:
Phone#: (336)998-9115 Phone#:
Property Location & Site Information
Address/Road#: Subdivision: Stonemoor Phase: Lot: 8
824 Markland Rd
dvance NC 27006 Directions
acture: SINGLE FAMILY Hwy 64 east left on Hwy 801. approx 4 miles Markland
Rd. on left. Property on left
#of Bedrooms: 4
#of People:
*Water Supply: NSA
System Specifications
Minimum Trench Depth: a 4 Inches
Site Classification: .Provisionally suitable _.
Minimum Soil Cover. 1 a
Saprolite System? OYes XNo Inches
Design Flow: - - -4 8 0 Maximum Trench Depth:- 3 6 Inches
Soil Application Rate: 0 a r, Maximum Soil Cover: a 4 Inches
*System Classification/Description: *Distribution Type:_ GRAVITY-PARALLEL(eq.d-box)
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0
Gallons
*Proposed System: 25%REDUCTION 1-Piece: O Yes ®No
Pump Required: O Yes O No (&May Be Required
Nitrification Field 1 7 4 5
Sq.ft. Pump Tank: Gallons
No. Drain Lines 4 1-Piece: Oyes ®No
Total Trench Length: 4 3 6GPM--vs— ft. TDH
ft. _
Trench Spacing: — 9 OInches O.C. —
®Feet O.C. Dosing Volume: Gallons
Trench Width: 3 Inches
AFeet Grease Trap: Gallons
Aggregate Depth:
inches Pre-Treatment: O NSF OTS-1 OTS-11
Septic Tank Installer Grade Level Required: 01 OII 0111 01V
Page 1 of 3
CDP File Number 138034- 1 County ID Number:
❑ Open Pump System Sheet
Repair System Required:0 Yes O No O No, but has Available Space
Repair System Inches O.C.
Trench Spacing: 9 O
*Site Classification: Provisionally suitable — ®Feet O.C.
Trench Width: Inches
Design Flow: 4 8 0 3 Feet
Soil Application Rate: 0 - ,) 7 5 Aggregate Depth: inches
Minimum Trench Depth: � (i, Inches
*System Classification/Description:
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Minimum Soil Cover:
LESS) 1 Inches
*Proposed System: 25%
Maximum Trench Depth: 3 6 Inches
REDUCTION
Maximum Soil Cover: a q, Inches
Nitrification Field 1 7 4 rj Sq.ft. -
No.Drain Lines4 *Distribution Type: GRAVITY-PARALLEL(eq.d-box)
Total Trench Length: 4 3 6 ft, Pump Required: QYes Q No ®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. R mrv�
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. Ramming
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 130A336(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: 2140-Nations,Robert Date of Issue: 0 5 / 0 6 / .2 0 1 4
Authorized State Agent: Malfunction Log Oyes
(&Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION 138034 - 1
Davie County Health Department CDP File Number:
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 05 / 06 / .2014
O Inch
Drawing Drawing Type: Construction Authorization Scale: OO N/Ak
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Page 3 of 3
P1 P2
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street CDP File Number: 138034 - 1
P.O.Box 848
Mocksville NC 27028 County File Number:
Date: .0.5./.0.6./..10.1.4.
Click below to import an image from an external location: Drawing Type: Construction Authorization
Page 3 of 3
P1 P2
mor aN carol Parlor®G�vl�c�r►� _ �C,
APPLICATION FOR SITE EVALUATION/MTROVEMENT PERMIT&ATC
kA
�i/�ryt►sptreee
;2 V.4O PAW
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t ., ektgll Cyd 1y �` ,.• r t c� }
Date:
Application For. aSiteEvnhuatiowImprovementPermit lrAuthorizationToConstruct(ATC) Both M sp
Type of Application: 'hlew System ❑Repair to Existing System ❑Expensior✓Modification of Existing System or Facility &WIVed bYt ''`/V
•••IMPORTANT"'THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Nam tobe Billed �� _Contact Person
Billing Address Home Phone a56 em—MTL
—
City/State/ZIP Business Phone
Name on Permit/ATC ifD�erent than Above OS if*eO
Mailing Address City/Statelzi
PROPERTY INFORMATION 'Date House/Facility Corners Flagged
NOTE: A survey plat or site plan must accompany this application. Included:$Site Plan OPfat(to scale)
(Permit is elid for 60 mcntte plan,no expiration complete plat)
Owner's Name, i le%,I.= Phone Numb-_SX-As 4ZY0
Owner's Address City/S ate/Zip /�i9Nt - NG 27cic�
Property Address 82 , Nd w0 - City iYet
Lot Si=.A.9Q_�ed_ce Tax PIAT# ZZ 2S I
Subdivision Name(ifapplicabla dZ&AM& Section/Lot# $
ons To Site: LE .
Ar AC
If the answer to any of the following questions is"yes",supporting documentation must be attached.
Are there any existing wastewater systems on the site? ❑Ye=
Does the site contain jurisdictional wetlands? ❑Yes BIV0
Are there any easements or right-of-ways on the site? ❑YesliJ'No
Is the site subject to approval by another public agency? ❑Yes Mwo
Will wastewater other than domestic sewage be generated? ❑Yes AINo
IF RESIDENCE FILL OUT THE BOX BELOW
#People #Bedrooms #Bathrooms Garden Tub/Whirlpool❑Yes;hUo
Basement:)Ws ONo Basement Plumbin :Wes ONo
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 systemrequested Wonventional ❑Accepted ❑imwvative ❑Altemative ❑Other -
Water Supply Type: County/City Water ❑New Well OMsting Well ❑Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve?O Yes C to
If yes,what type?
This is to certify that the information provided an this application is true and correct to the best of my knowledge. I understand
that any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use
changes,or if the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized
Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable
taws and les I urs am responsible for the proper identification and labeling of property lines and Comm and
d n tat' the ho facility location,proposed well location and the location of any other amenities.
ty owner's or� egal repres 've signatuma Site Revisit Charge
Date(s):
Z Y client Notification Data
D4. MS:
Sign given ❑Yes ONo Account# 1.5903
Revised 11/06 Invoice#
....................
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GRAPHIC 5C LE - FEET «
C
kIPP ON FOR SITE CVALLIAT 10N/lAII)BOVEMENT PERMIT&ATC -�-
Davie County Health Department (�
Envirunmental Health Section
f �. P.O. Dor 048/210 hospital.Street ' A\
V Mocrsvilla NC 27028 `
(336)751-8760
s GN;i1�^ti�i PITAL HEALiH,
***.T1'IPORT11N1`* *-'PIfT CATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFOM-1ATION IS PROVIDED. Refer for the INFORbIATION BULLETIN for \instructions.
1. Name +e-bead /moo' a r1t1 Contact Person
Mailing Address )1(0 p4e�— prI Se- home Phono �� 2— (l9 3
City/stata/ZIP La kc, 5Ye 5'�. CA D,�6.j 0 Business Pliono
L
2. Name on Pormit/ATC if Different than Above
Mailing Address City/state/Zip
a. Application For KSitc Evaluation ❑ Improvement Permit/ATC ❑ Both
4. System to Service: House ❑ 14obilo Homo ❑ Business ❑ Industry', ❑ Other
S. Typo system requested: 0 Conventional ❑ conventional modified ❑ innovative I3acCepted
6. If •ltoaidenco: U People a Bedrooms U Bathrooms 3
!
4iahwaahar ACarbago Disposal Mtlashing Machina Basement/Pluming ❑naacmont/No Plumbing
7. If• Dual neas/Industry /othor: verify`typo 9 People U Sinks
9 Commotion U Showers 9 Urinals 9 Nater Coolers
IF FOODSERVICE: 0 Seats Estimated Water Usage (gallons par day)
S. Type of water supply: County/City ❑ well ❑ Community
9. Do you anticipate additions or expansions of.tlie facility this sysienl is intended to serve?❑Yes ❑ No
If)•cs,iviat type?
***1J1f1'0RTi1NP**CLIENTSAMSTCU:IIPLETE THE REQUIRED PROPERTY I11I7-011IIATION RI'QUEs-rED
BELOW. dither n PLAT or SITE PLAN:1fU.ST AUSUAMITTED by(lie client with THIS APPLICATION.
1 roperty Diniensiot WRITE DIREMONS(frum 11•Iuc(stiillc)to PROPERTY:'
ERTI:'
Tax office I'M li .�`�� 9/� d �7�-SHurm i5 ' Ale )( R01 S
Property Address: Road Name 111cul 4' 1<xihd-F L 9 Gly, MCA r IL t 1�
City r(l
/Zip�cl, Q'Yl�C /��, �CL�'1 G� � n� i � L7� L t'
If in a Stibdivision provide infoi•niatiolt,as folloivs:
Name: •
/
Sec(ion: Block: Lot: / Date lionle corners flagged: /Zel'Of,I
This is to certify that the information provided is correct to the best of Iuy knowledge. I understand tliat any perniii(s)
issued licrcafter arc subject to suspension or revocation,if tic site plans or intended use change,or if the information
submitted in (his application is falsified or changed. I,also,Iuulerstand that I aal reaponsibleforall charges hicurrellfroin
this application. I,liereby,give consent to the Authorized Representative of the Davie County I•Ieil(li Departulent
to enter upon above described property located in Davic County and oivnc(lby
to conduct all testing procedures as necessary to dcia•uiiuc the site suitability.
DATE lZ 6f SIGNATURE
TIIIS AREA MAYBE USED FOR DRAWING YOUR SITE PLAN(Include all of tic following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Datc(s):
t/ Client Notification Date:
I-aIS:
given
Sign ' ,,Account No. u
b ��/
Revised DCIID(05103 7 Invoice No.
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1 X
DAVIE COUNTY HEALTH DEPARTMENT
--' Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003812 Tax PIN/EH#: 5789-16-0725.08
Billed To: Andrew Reynolds Subdivision Info:
Reference Name: Location/Address: Markland Road-2702
Proposed Facility: Residence Property Size: 11.57 acres Date Evaluated: 1 10 DSC
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit '� Cut
FACTORS 1 2 3 4 5 6 7
Landscape position S
Slope%
HORIZON I DEPTH
Texture group e I 5c_� C41,
Consistence R_S55rs;5
Structure
Mineralogy5+
HORIZON I1 DEPTH • j
Texture groupS L S L
Consistence V $
Structure 5
Mineralogy
HORIZON III DEPTH .3
Texture group5C}�,
Consistence FrSn, F-r S
Structure
Mineralogy
HORIZON IV DEPTH 32•-5—
Texture group (ILS S(l-
Consistence NSA S9
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE S S
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
n Ly
SITE CLASSIFICATION: `I S EVALUATION BY: TT� _ ,.i0
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
ro
REMARKS: y Luxit SvLS O i D e H
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
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
maw
VFR-Very friable FR Friable FI Firm VFI Very firm EFI-Extremely firm
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
LIQte.T
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 05105(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
PO Box 848/210 Hospital Street
Mocksville, NC 27028
Phone: (336)751-8760 /Fax: (336)751-8786
January 23, 2006
Andrew Reynolds .
26244 Enterprise Ct.
Lake Forest CA 92630
Re: Site Evaluation-
Stonemoor Subdivision-Markland Rd.
Lot#7—5.33 Acre Tract
Lot#8—6:2 Acre Tract
Tax PIN#: 5789160725
Dear Client(s):
As requested, a representative from this office visited the above sites January 10,
2006 to perform site evaluations. Based on the information provided on the Application
for Site Evaluation and after the evaluations were completed,both sites were found to be
provisionally suitable for the installation of an on-site sewage disposal system.
House location and size, soil conditions, topography,. surface water proximity and
other design criteria may necessitate the use of a pump station and/or an
alternative/innovative system. System design will be determined at the time an
Improvement PermitMuthorization to Construct is applied for and issued.
Before a representative of this office will revisit the site to issue an Improvement
Permit/Authorization to Construct,the appropriate application must be completed and
submitted to this office. The location of the facility the system is to serve must be staked
off.
If you have any questions, feel free to contact this office at 751-8760.
Sincerely,
Jeff G.Beauchamp,R. .
Environmental Health Section
Enc(s)
• / I
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