157 Sweet Creek Trail OPERATION PERMIT F*CDPFileNumber
ice use nv
a�swc� Davie County Health Department 219789-1
210 Hospital Street 5830991837
mber.
P.O.Box 848
Mocksville NC 27028 Evaluated For. REPAIR
Phone:336-753-6780 Fax:336-753-1680 Township:
F
ant: Heidi Andrews Property Owner. Heidi Andrews
ss: 157 Sweet Creek Trail Address: 157 Sweet Creek Trail
yMocksville City: Mocksville
State2ip: NC 27028 'State/Zip: NC 27028
Phone#: (336)909-1257 Phone#: (336)909-1257
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
157 Sweet Creek Trail
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Off of Angell Road
#of Bedrooms:
#of People:
*Water Supply: tVA
*IP Issued by. *System Classification/Description:
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by: 2140-Nations,Robert
Saprolite System? OYes ONo
Design Flow: 3 6 0 GRAVITY-SERIAL Pump Required?
Distribution Type: OYes QNo
Soil Application Rate: 0 - a 3 5 *Pre Treatment:
s Drain field
N rification Field 1 3 0 9 Sq.ft. *System Type:
No,Drain Lines 1 Installer: RandyMitter
Zotal Trench Length: 3 3 6 8• Certification#: 1128
Trench Spacing: _ 9 Inches O.C.
Feet O.C. *ENS: 2140-Nations,Robert
Trench Width: _ 3 Oln des
Date: 0 7 / 0 8 / 2 0 1 6
M.
Agg reg ate;Depth: inches
Minimum.Trench Depth: 3 6
Inches
Minimum Soil Cover. 4 App
Inches rovat Status
Maximum Trench Depth: 3 6 ® Approved O Dlsappi=oveu=
Inches
Maximum Soil Cover: Inches
CDP File Number 219789 - 1 Septic Tank County ID Number: 30991837
'
Manufacturer. Lat.
Long:
STS: - -
Gallons: Installer
Date: Certification#:
*EHS:
*Filter Brand:
ST Marker. ❑ Yes ❑ NO Date.
Reinforced Tank: ❑ Yes ❑ NO Approval Status
❑ Approved❑UDtsapprove(
1 Piece Tank: ❑ Yes ❑ No _ -
Pump Tank
Manufacturer. Installer
PT: Certification#:
Gallons: *EHS:
..Date: Date: r
RiserSealed ❑ Yes ❑ No
RiserHeght: ❑ Yes ❑ No (Min.6 in.)
Approval Status
1einforc ed Tank: ❑ Yes ❑ No
❑ Approved❑ Disapproved
1 Piece Tank: ❑ Yes ❑ No
Supply Line
Pipe Size: inch diameter Installer.
Pipe Length: feet Certification#:
*Schedule: *EHS:
Pressure Rated ❑ Yes ❑ No Date:
Approved fittings ❑ Yes ❑ No Approval Status
❑ Approved ❑ ;Disapproved
Pump Requirement
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 Appraval5tatus,
PVC unions C1 Yes C1 No ❑":Approved❑ Disapproved
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole C1 Yes ❑ NO
CDP File Number 219789 - 1 County ID Number: 30991837
Electric Equipment
NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer
Box 12 inches Above Grade ❑ Yes ❑ No Certification#:
Box Box
Pump Tank ❑ Yes ❑ No
Conduit Sealed ❑ Yes ❑ NO 'EHS:
Pump Manually Operable ❑ Yes ❑ No
'Activation Method: Date:
5pproVal Status
Alarm Audible E3 Yes ❑ No F1 Approvetl❑ Disapproved
Alarm Visible ❑ Yes ❑ No
2140-Nations,Robert
'Operation Permit completed by:
Authorized State Agent:—- Date of Issue: 0 7 / 0 5 / a 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 It A. sewage septic system,
Rule.1961 requires that a Type TYPE II p` septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: N/A
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency By Certified Operator:
N/A
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 entitywith a certified operatoror a private certified operator forthe life of the 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 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 entry,unless the
system owner and certified operator are the same. The contract shall require specific requirements for maintenance and
operation, responsibiities 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.
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT 219789 - 1
Davie County Health Department CDP File Number:
210 Hospital Street5830991837
P.O.Box 848 County File Number:
Mocksvilie NC 27028 Date:
Q Inch
Drawing Drawing Ty e: Operation Permit Scale: . Oelocic
0N/A
4
I
I I
o
' CONSTRUCTION For officeUse only
4 'AUTHORIZATION *COP File Number 219789-1
00
Davie County Health Department County ID Number:5830991837
210 Hospital Street Evaluated For. REPAIR
.� �. P.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone: 336-753-6780 Fax:336-753-1680 0 6 / 2 4 / a 0 a 1
Applicant: Heidi Andrews
r
erty Owner Heidi Andrews
Address: 157 Sweet Creek Trail ress: 157 Sweet Creek Trail
City: Mocksville City: Mocksville
State/Zip: NC 27028 State/Zip: NC 27028
Phone#: (336)909-1257 Phone#: (336)909-1257
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
157 Sweet Creek Trail
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Off of Angell Road
#of Bedrooms:
#of People:
"Water Supply: WA
- System Specifications
Minimum Trench Depth: a 4
(Design
te Classification: Provisionally Suitable Inches
Minimum Soil Cover. 1 a
proliEe System? QYes QNo Inches
Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches
SoilMaximum Soil Cover:
Application Rate: 0 a7 5 a 4 Inches
"System Classification/Description: 'Distribution Type: GRAVITY-SERIAL
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
_ _ Gallons
"Proposed System: 25%REDUCTION 1-Piece: QYes QNo
Pump Required: QYes QNo OMay BeRequired
Nitrification Field 1 3 0 9 Sq ft Pump Tank: Gallons
No. Drain Lines 5 1-Piece: QYes QNo
Total Trench Length: 3 a GPM—vs— ft. TDH
Trench Spacing: 9 @Feet O.C.Inches O.C.
_ Dosing Volume: _ Gallons
Trench Width: _ Inches
3 Feet Grease Trap: Gallons
Aggregate Depth:
inches Pre Treatment: ONSF OTS-I OTS-II
Septic Tank InstallerGrade Level Required: 01011 0111 OIV
Donn 9 of 4
CDP File Number 219789 - 1 County ID Number,583A91837
❑ Open Pump System Sheet
Repair system Required:OYes ONo ONo, but has Available Space
rDesign
System Trench Spacing: Inches 0.0
ification: — Feet O.C.
Trench Width: Q Inches
w: — o Feet
Soil Application Rate: Aggregate Depth: inches
*System Classification/Description: Minimum Trench Depth: Inches
Minimum Soil Cover. Inches
Maximum Trench Depth: Inches
*Proposed System: ,
Maximum Soil Cover:
Nitrification Field Sq. Inches
ft.
No. Drain Lines *Distribution Type:
_Total Trench Length: Pump Required: OYes ONo 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.
*Permit Conditions
The issuance of this permit bythe 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.
This Authorization for Wastewater System Construction shall be valld 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(1;)�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: 7140-Nations,Robert Date of Issue: . 0 6 / a 4 / 2 0 1 6
Authorized State Age Malfunction Log OYeS
®Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION 219789 - 1
Davie County Health Department CDP File Number:
210 Hospital Street 5830991837
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 0 6 / .2 4 / 2 0 1 6
Q Inch _
Drawing Drawing Type: Construction Authorization Scale: . ()Block
k
N/A ft.
LAI-
fit
i
_ I
1
1
I
I � I
� I I
I
CONSTRUCTION AUTHORIZATION R r
Davie County Health Department
210 Hospital Street CDP File Number: 219789- 1
P.O.Box 848 5836991837
Mocksville NC 27028 County File Number:
Date: .0 .6 / 24 12 0 1 6
Click elow to Im ort an Image from an external location: Drawing Type:Construction Authorization
d
O
W`
l-
"7S c
i
1 `e.
4 � I
Davie COUNTY
210 Hospital Street
P.O. Box 848
Mocksville NC 27028 TEL: 336-753-6780 FAX: 336-753-1680 Request ID: 66584
REQUEST FOR SERVICE/COMPLAINT INVESTIGATION REPORT
REQUEST DATE: 06/20/2016 TARN BY:
SECTION: N/A TYPE:
PROPERTY NUMBER: 219789 ASSIGNED TO: Nations, Robert
ESTABLISHMENT NUMBER:
PERSON OR PREMISES TO SEE: OWNER: Heidi Andrews
Heidi Andrews 157 Sweet Creek Trail
157 Sweet Creek Trail Mocksville , 27028
Mocksville NC, 27028
(336) 909-1257
REQUESTED BY: HOME:
WORK:
Cell:
Additional Information:
Y�
CONDITION REPORTED:Pumped in November surfacing around tank
COMMENTS:
RECORD OF INVESTIGATION
DATE: HR/MT: COMMENTS
EHS:
EHS #:
ACT CODE:
DATE: HR/MT: COMMENTS
EHS:
EHS #:
ACT CODE:
DATE: HR/MT: COMMENTS
EHS:
EHS #:
ACT CODE:
DATE: HR/MT: COMMENTS
EHS:
EHS #:
ACT CODE:
DATE: HR/MT: COMMENTS
EHS:
EHS #:
ACT CODE:
Next Inspection Date: Status of Complaint: OPEN Resolved Date:
Complaintant Contacted: NO
qoj Aw
DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST
APPLICATION IP/ATC OSWW REPAIR
Name / 4141-e W Telephon Number 3?�f
Address :5U) Tra i —or V( 0 lVG
Mailing Address (if different from above)
Email Address:
Subdivision Name Lot#
Directions
Date System Installed g s Name System Installed Under e /�
Type Facility d us-e" Number Bedrooms Number People Served
TypQ Water SUP121Y Specifi Problem Occurring
No
Date Requested Info Taken By . bock
THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY
KNOWLEDGE,AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED
FROM THIS APPLICATION.
Signature of owner or Authorized Agent
Initial Fee Date RE HS
Revisit Charge Date Reason I
Revised 2-2011