197 Twin Cedars Golf Rdy
OPERATION PERMIT
Davie County Health Department
T 210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: John Singleton
Address: 197 Twin Cedars Golf Road
City: Mocksville
State2ip: NC 27028
Phone #: (336) 251-8561
Address/Road #:
197 Twin Cedars Golf Road
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms:
# of People:
'Water Supply: PUBLIC
*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 193846-1
5746271980
County ID Number.
Evaluated For. REPAIR
� Township:
/'Property Owner: John Singleton
Address: 602 Singleton Road
City: Mocksville
State2ip: NC 27028
Phone 4: (336) 251-8561
ierty Location & Site information
Subdivision: Phase:
Directions
Hwy 601 South
Lot:
*System Classification/Description:
TYPE 11 A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
Saprolite System? OYes QNo
'Distribution Type: GRAVITY- PARALLEL (eq. d.box) Pump Required?
QYes QNo
'Pre Treatment:
Drain
1 a 0 0 Sq. ft.
4
3 0 0 ft.
9 Olnches O.C.
Feet O.C.
Qlnches
e 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: Mike Singleton
Certification #: 1819
*EH S: 2140- Nations, Robert
Date: 0 3/ 0 3/ 2 0 1 6
Inches
Inches Approval Status
Inches M Approved 0 Disapproved
Inches
CDP File Number 193846 - 1
Manufacturer.
County ID Number: 5746271980
c Tank
Lat.
Long:
STB:
Gallons:
Installer.
Date: / / Certification 4:
*EH S:
*Filter Brand:
ST Marker: 11 Yes ❑ No Date:
einforced Tank: ❑ Yes F1No Approval Status
Piece Tank: O Yes 13 No
❑ Approved ❑ Disapproved
Pump Tank
Manufacturer Installer.
PT: Certification #:
Gallons: *EH S:
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
Date: /
Approval Status
_Q'Approved ❑ Disapproved
Supply Line
Installer.
Certification #:
*EH S:
Date:
Approval Status
❑ Approved ❑ Disapproved
J
/ Pump Type: Installer.
r Dosing Volume: — Gal Certification 9:
Draw Down: Inches *EHS:
*Chau:
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
Anti -siphon Hole 0 Yes
❑
❑
No
No
CDP File Number 193846-1
ClUGUIG CUUIL MU11L
County ID Number: 5746271980
NEMA 4X Box or Equivalent
❑ Yes
❑
No
Installer:
Box 12 inches Above Grade
❑
Yes
❑
NO
Certification #:
Box Adj. To Pump Tank
❑
Yes
❑
No
Conduit Sealed
❑
Yes
❑
No
'EH S:
Pump Manually Operable
❑
Yes
❑
NO
*Activation Method:
Date:
AlarmAudible
❑Yes
❑
No
Approval Status
❑ Approved❑'Disapproved
Alarm Visible
❑
Yes
❑
No
Operation re ---
Authorized St
2140 - Nations, Robert
Owner/Applicant Signature:
r/ 0 3/ 2 0 1 6
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 11 A. septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: WA—
Management Entity: OWNER
Maximum System Inspection/Maintenance Frequency By Certified Operator:
N/A
Reporting Frequency By Certified Operator: NA
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 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 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
Drawing Drawing Type: Operation Permit
CDP File Number: 193846-1
County File Number: 5746271980
27028 Date: ! /
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CONSTRUCTION
AUTHORIZATION
Davie County Health Department
210 Hospital Street
w P.O. Box 848
Mocksville NC 27028
For Office Use Only
*CDP File Number 193846 - 1
County ID Number: 5746271980
Evaluated For: REPAIR
k jownship:
Phone: 336-753-6780 Fax: 336-753-1680 0 6/ 1 9/ a 0 a 0
Applicant: John Singleton
Address: 197 Twin Cedars Gold Road
City: Mocksville
State/Zip: NC 27028
Phone #: (336) 251-8561
erty Location
Property Owner: John Singleton
Address: 602 Singleton Road
City: Mocksville
State/Zip: NC 27028
Phone #: (336) 251-8561
/"Address/Road #: Subdivision:
197 Twin Cedars Gold Road
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 601 South
# of Bedrooms:
# of People:
"Water Supply: PUBLIC
Phase: Lot:
Page 1 of 3
Minimum Trench Depth: a 4 Inches
\Site
Classification:
Provisionally suitable
Sa rolite System?
p y
O Yes � No
Minimum Soil Cover: 1
Inches
Design Flow:
3 6 0
Maximum Trench Depth: 3 6 Inches
Soil Application Rate:
0 3
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:
Gallons
*Proposed System: 25% REDUCTION
1 -Piece: O Yes O No
Pump Required: O Yes O No O May Be Required
Nitrification Field
1 a 0
Sq. ft. Pump Tank: Gallons
No. Drain Lines
3
1 -Piece: OYes ONo
Total Trench Length:
3 0 0
GPM --vs-- ft. TDH
ft.
Trench Spacing:O
_ 9
®
Inches O.C.
Feet O.C. Dosing Volume: _ Gallons
Trench Width:
3O
®
Inches
Feet
_
Grease Trap: Gallons
Aggregate Depth:
inches Pre -Treatment: O NSF OTS -1 O TS -II /
Septic Tank Installer Grade Level Required: 01 011' O 111 ON
Page 1 of 3
CDP File Number 193846 - 1
Repair System Required:0Yes ONO
County ID Number: 5746271980
❑ Open Pump System Sheet
ONO, but has Available Space
Repair System
Trench Spacing:
In .
9 Oches O.
*Site Classification: Provisionally suitable
1
— ®Feet O.C.
Trench Width:j
Inches
3 Feet
Design Flow: 3 6 0
—
Aggregate Depth:
Soil Application Rate: 0 3
inches
Minimum Trench Depth:
a 4,
*System Classification/Description:
Inches
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR
Minimum Soil Cover:
1 a Inches
LESS)
Maximum Trench Depth:
3 6
*Proposed System: 25% REDUCTION
Inches
Maximum Soil Cover:
a 4, Inches
Nitrification Field 1 a 0 0 Sq. ft.
_
*Distribution Type:
GRAVITY - PARALLEL (eq. d -box)
No. Drain Lines 3
Total Trench Length: 3 0 0Pump Required: OYes
(& No O May Be Required
ft.
I
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. 2-i s
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. Rame ; g
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(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? O Yes O No
Applicant/Legal Reps. Signature- Date:
*Issued By: 2140 - Nations, Robert Date of Issue: 0 6 / 1 9
Authorized State Agent:
Malfunction Log Oyes
® Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
a
0
1
5
Malfunction Log Oyes
® Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
CDP File Number: 193846 - 1
County File Number: 5746271980
Date: 06/ 19 /x015
O Inch
SrAp- n Blork = ft.
Page 3 of 3
P1 P2
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street CDP File Number: 193846-1
P.O. Box 848 5746271980
Mocksville NC 27028 County File Number:
Date:.�.6./.1.9./..1 0 1.5.
Click below to import an image from anexternal location: awing Type: Construction Authorization
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