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105 Timber Creek RdOPERATION PERMIT Davie County Health Department * f� 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753.6780 Fax: 336-753-1680 Applicant: Helen Butner/Michael ch Aon bwland Address: 105 Timber Creek City Advance State2ip: NC 27006 Phone #: ro Address/Road M 105 Timber Creek Advance NC 27006 Structure: SINGLE FAMILY # of Bedrooms: 3 # of People: *Water Supply: NIA *IP Issued by. *CA issued by: 2140. Nations, Robert Design Flow: 3 6 0 Soil Application Rate: 0 - 3 Nitrification Field No. Drain Lines Total Trench Length Trench Spacing: Trench Width: Aggregate Depth: *CDP File Number 124538-1 E7-000-MI52-06 County ID Number: Evaluated For: HDR/WWC Township: Property Owner: Helen Butner/Michael Address: 105 Timber Creek City Advance State/Zip: NC 27006 Phone #: Ierty Location & Site Information Subdivision: Phase: Lot: Directions Hwy 158 East, right on Gun club Rd. House on corner, of Development *System Classification/Description: TYPE 11 A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Saprotite System? Q Yes q)N o *Distribution Type: GRAVITY- SERIAL Pump Required? QYes No *Pre -Treatment: Drain field 1 a 0 0 Sq. ft. 7 3 0 0 ft. 9 Inches O.C. Feet O.C. 3 Inches Feet inches Minimum Trench Depth: 3 6 Minimum Soil Cover. a 4 Maximum Trench Depth: 3 6 Maximum Soil Cover: a 4 *System Type: INFILTRATOR QUICK 4 STANDARD Installer: Brian Beebe Certification #: 3260 *EH S: 2140 - Nations. Robert Date: 0 3/ a 9/ a 0 1 6 Inches Inches Approval Status Inches ® Approved O Disapproved Inches CDP File Number 124538 - 1 County ID Number: E7.000'00-152-06 Manufacturer. Lat. Long: STB: Gallons: / / Installer: Date: / No / Certification #: ❑ No (Min.6 in.) nforced Tank: ❑ Yes *EHS: *Filter Brand: 1 Piece Tank: ❑ Yes ❑ NO ST Marker: ❑ Yes ❑ No Date: Reinforced Tank: ❑ Yes ❑ No ❑ Approval Status \ Anti -siphon Hole ❑ Yes 0 No ❑Approved ❑ Disapproved 1 Piece Tank: ❑YeS ❑ No Pump Tank Manufacturer. W Gallons: Date: / / RiserSealed ❑ Yes ❑ No RiserHeight: ❑ Yes ❑ No (Min.6 in.) nforced Tank: ❑ Yes ❑ No 1 Piece Tank: ❑ Yes ❑ NO / Pipe Size: inch diameter Pipe Length: feet 'Schedule: Pressure Rated ❑ Yes ❑ No Approved fittings ❑ Yes ❑ No Installer. Certification #: *EH S: Date: / Approval Status ❑ Approved ❑ disapproved upply Line Installer: Certification #: 'EHS: Date: Approval Status ❑ 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 0 No CDP File Number 124538 -1 County ID Number: E7•000 -M152-06 Electric Equipment NEMA 4X Box or Equivalent El Yes ❑ No Installer: Box 12 inches Above Grade ❑ Yes ❑ No Certification 9: Box Adj. To Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No *EHS: Pump Manually Operable ❑ Yes ❑ No *Activation Method: Date: Alarm Audible E3 Yes 1:1No Approval Status ❑ Approved[] Disapproved Alarm Visible ❑ Yes ❑ No 2140 - Nations. Robert *Operation Permit completed by: Authorized State Agent: -'~ -'" Date of Issue: 0 3 / a 9 / 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.k sewage septic system. Rule .1961 requires that a Type m'E IIA 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: NIA 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 entitywth a certified operatoror 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 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 Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Type: Operation Permit CDP File Number: 124538-1 County File Number: 127-400-M152-06 Date: / J Olnch Scale: OBlock ON/A i I E I I I � 3 I ' 1 46 L-A ------------ I I zf t { .-,,. ,,.. --'---tom, ,.,.. �_......_. .,_.._,� .. ............ i i II � = t DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 /Fax # (336)753-1680 OPERATION PERMIT Account #: 990006156 Billed To: Helen Butner Reference Name: EXPANSION Proposed Facility: Residential Expansion a F/y, �" 3�) 110 Tax PINJEH #: E7-000-00-152-06 Subdivision Info: LocationiAddress: 105 Timber Creek Drive -27006 Property Size: 1 Ac ATC Number: 6050 **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY'be taken as a guarantee that the system will function satisfactorily for any given period of time. System Type:_ S.T. Manufacturer Tank Date Tank Size Pump Tank Size Bedrooms: System Installed By: Installer# Date: GPS Coordinate: Environmental Health Specialist Date: DCHD 11106 (Revised) • DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street. Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990006156 Tax PIN.%EH #: E7-000-00-152-06 Billed To: Helen Butner Subdivision Info: Deference Name: EXPANSION LocationfAddress: 105 Timber Creek Drive -27006 Proposed Facility: Residential Expansion Properly Size: 1 Ac ATC Number: 6050 Site Type: ❑New ❑Repair HExpansion **NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. Residential Specifications: # Bedrooms # Bathrooms # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size ue f e- Type of Water Supply: 21,ounty/City ❑ Well ❑ Community Well Y� System Specifications: Design Wastewater Flow (GPD) 3 Tank Size FX t AL.Tump Tank 14&AL. r� 1 Trench Width '34:1 Max. Trench Depth_ � (00 � Rock DepthA5 Linear Ft. 3 Site Modifications/Conditions/Other: A5 �'�� , , )`7 Contact the Davie County Environmental Health Section for final inspection of this system between 8:30 = 9:30a.m. on the day of installation. Telephone # (336)751-8760. to _7 �P X341 g toM4�'o°-f a��oRadu�f:v- � a5G Environmental Health Specialisf"��%JDate: /_? `a 7_11-31 DCHD 11/06 (Revised) Davie County Health Department o X836 Environmental Health Section P.O. Box 848 RECEIVEDMoll 210 Hospital Street 'I p v 1 Date; z f6 Courier #: 09-40-06 ocksville, NC 27028 Phone: (336) - 753 - 6780 Fax: (336) - 751-8786 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection Name: / Phone Number 376 (Home) Mailing Address: (Work) /or) 1W u A) L. .2 -7 0 LS Email Mich L, deta ,g s&� r"� r ► � ' U'r`' Detailed Directions To Site: D -t G G, nl C 114 ff Property Address: /0 Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: '< k2w �� G[ L� Type Of Facility: 1 ILC Date System Installed (Month/Date/Year):/,;?/(I)Number Of Bedrooms:__a_Number Of People: Is The Facility, Currently Vacant? Yes S If Yes, For How Long? Any.Known Problems? Yes IFIN No If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: a12 oojO CYJ/t1 Number Of Bedrooms:_Number of People /Requested By: Date Requested: JZ (Signature) For Environmental Health Office Use Only Approved Dixroved Comments: UO kc/ t, '1K1 nU7'a lG Environmental Health Specialist /�L / In15� 1 �i A�k, 1 2 66 V �I I � >,`i • f V II W � Y ,porn c5s�i6 x,11 7 'do 3 CP ti I do ZjfZ �rn All data is provided as is without warranty or guarantee of any kind either expressed or implied Including but not limited to the implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of C 111; Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out of the use or inability to use the GIS data provided by this website. Pn n + led. Dec 06, 2013 DAVIE COUNTY HEALTH DEPARTMENT Vl IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a Sanitary Sewage System C� Permit Number Name �� 2 "� } — _-- Date y _—Ly? N2 8166 Location I A_ Subdivision Name lot No. Sec. or Block No. Lot Size 3 House — Mobile Home --_— Business _— Industry No. Bedrooms No. Baths ---- No. in Family — Public Assembly Other Garbage Disposal YES0 ❑ Specifications f r S stt m•�� Auto Dish Washer YES �0 ❑ C ;odd ,- `� .3 Auto Wash Ma^hine YES g; -'IN 0 0 Type Water Supply *This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS SYSTEM. t p �r Ro 0 S- � Improvements permit by ------ w *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M., 1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634.5985. Final Installation Diagram: Systtem`Installed byC-t -. Certificate of Completion Date Date w_ 'The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. r, �► - ,,� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested Mailing Address { 2. Name on Permit if Different than Above 3. Application for: 4. System to Serve: ❑ Business 5. If house, mobile home: Subdivision _ ❑ General Evaluation 012' House ❑ Mobile Home ❑ Place of Public Assembly ❑ Industry ❑ Other ❑ Unknown Ll ptic Tank Installation Permit No. of People No. of Bedrooms No. of Bathrooms tt Dwelling Dimensions :2 b 1 6 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Sinks _ No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: IYPublic ❑ Private 8. Property Dimensions J,Sewage Disposal Contractoi 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? If yes, what type? Section Lot # ❑ Basement/Plumbing ❑ Basement/No Plumbing Er/Washing Machine Dishwasher 0?'Garbage Disposal ❑ Yes ❑ No ❑ Community 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: M,,y Isl �- k+- heP C -1w1 -f L �, Z This is to certify that the information provided is correct to the best of my knowledge, incurred-fromthis application. L DATE I understand I am responsible for all charges SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. ErZ I DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine said site's suitability for a grou d absorption wage treatment and disposal system. DAT15 AIGINATILIAP DCHD (t 193) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation (� NAME Cs. '1 4 (� `� \�Q� DATE EVALUATED - I� ADDRESS 5 A T'.Z�R PROPERTY SIZE I Cb - PROPOSED FACIILTY \_\a 13 LOCATION OF SITE G Water Supply: On -Site Well _ Community Public Evaluation Byz l�jL Auger Boring ✓ Pit Cut FACTORS 1 2 3 4 Landscape position S S S' Slope Z ,) o �- S" HORIZON I DEPTH • ' '' '' Texture groupL C C L. C lr Consistence F L Structure C, P Mineralogy ) : / HORIZON II DEPTH tq 21' Ll 2'` IT Texture group (-- °Consistence Consistence 1 i va Structure 8\_1' I 6X k K Mineralogy! I C HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS SS .SS S SS RESTRICTIVE HORIZON -' -- - - SAPROLITE — - - - CLASSIFICATION .S 75 , LONG-TERM ACCEPTANCE RATE ,moi `t SITE CLASSIFICATION: � .1> ' EVALUATED BY: LONG-TERM ACCEPTANCE RATE: �� OTHER(S) PRESENT,: e��R• REMARKS: Va V.` �_ 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 :lay loam- SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay CONSISTENCE Moist VFR- V ----y friable FR -Friable FI -Firm VFI-Very firm EFI-Extremely firm Wet NS -Non sticky SS -Slightly sticky S -Sticky VS -Very Sticky NP -Non plastic SP -Slightly plastic P -Plastic VP -Very plastic Structure 3C -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 (01-901 ■......■.■■...■..■/■/.IMAM■../...■......■... .■.. .■■IIIA■ MAMA■.■ ■IIIA/..IIIA ■.■.../.■■...■■■... ■■...■.. ...■.■■.■■■■.■■■..■/■. .................................................................. ............................................ ..................... ......................................... ........ ............. 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