1165 Williams RdOPERATION PERMIT
Davie County Health Department
° ¢ 210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant:
Evenda W. Hayes
Address:
1165 Williams Road
City:
Advance
State/Zip:
NC 27006
Phone #:
(336) 971-7318
Property Loca
Address/Road #: Subdivision:
1165 Williams Rd
Advance NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People: 2
*Water Supply: PUBLIC
*IP Issued by:
*CA Issued by: 2325 - Mitchell, Brittany
Design Flow: 3 6 0
Soil Application Rate: 0 a 5
Nitrification Field
No. Drain Lines
Total Trench Length
Trench Spacing:
Trench Width:
Aggregate Depth:
*CDP File Number 238500 - 1
5778177298
County ID Number:
Evaluated For: REPAIR
�ownship:
/Property Owner: Evenda W. Hayes
Address: 1165 Williams Road
City: Advance
State/Zip: NC
Phone #: (336) 971-7318
ion & Site Information
Phase:
Lot:
Hwy 64 East Left on Fork Bixby Rd. left on Williams
Rd. on the right
*System Classification/Description:
TYPE III G. OTHER NON-CONV. TRENCH SYSTEMS
Saprolite System? '.,Yes X, No
*Distribution Type: GRAVITY -SERIAL Pump Required?
0 Yes X No
*Pre -Treatment:
Drain field
Sq. ft.
5
350ft.
9 0Inches O.C.
®Feet O.C.
3 6 (gInches
0 Feet
inches
Minimum Trench Depth:
3
6
Inches
Minimum Soil Cover:
a
4
Inches
Maximum Trench Depth:
3
6
Inches
Maximum Soil Cover:
)
4
Inches
Page 1 of 4
*System Type: INFILTRATOR QUICK STANDARD
Installer: Brian McDaniel
Certification #: 11181
*EHS: 2325 - Mitchell, Brittany
Date: 0 5/ 1 0/.1 0 1 7
Approval Status
0 Approved ❑ Disapproved
CDP File Number 238500 - 1
County ID Number: 5778177298
Manufacturer:
PT:
se tic i anK
Gallons:
Manufacturer:
Existing
/
Lat.
❑ Yes
Riser Height:
❑ Yes
Reinforced Tank:
Long:
\ 1 Piece Tank:
STB:
*Schedule: 40
Inches
*EHS:
Pressure Rated ❑ Yes
❑ No
Date:
Installer:
Brian McDaniel
Gallons:
Approval Status
❑X
Approved ❑ Disapproved
Certification #:
11181
Date:
/
/
❑
No
Flow Adjustment Valve
*EHS:
Yes
*Filter Brand:
No
Check -valve
❑
Yes
❑
NO
ST Marker:
❑ Yes
❑ NO
Date:
❑
Reinforced Tank:
❑ Yes
❑ NO
Vent Hole
Approval Status
Yes
❑
NO
El
Approved El Disapproved
1 Piece Tank:
El Yes
El NO
❑
No
Manufacturer:
PT:
Gallons:
inch diameter
Date:
/
Riser Sealed
❑ Yes
Riser Height:
❑ Yes
Reinforced Tank:
❑ Yes
\ 1 Piece Tank:
❑ Yes
❑ No
❑ No (Min. 6 in.)
❑ No
❑ No
Pump Tank
Installer: Brian McDaniel
Certification #: 11181
*EHS:
Date:
Approval Status
❑ Approved ❑ Disapproved
/ Pump Type:
Supply Line
Pipe Size: 4
inch diameter
Installer:
Brian McDaniel
Pipe Length: rj
4 feet
Certification #:
11181
Gal Certification #:
11181
*EHS:
2325 - Mitchell, Brittany
*Schedule: 40
Inches
*EHS:
Pressure Rated ❑ Yes
❑ No
Date:
0 3/ 1 0/ x 0 1 7
Approved fittings ❑ Yes
❑ No
Approval Status
❑X
Approved ❑ Disapproved
Date:
Valves Accessible
/ Pump Type:
Installer:
Brian McDaniel
Dosing Volume:
-
Gal Certification #:
11181
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
❑
No
Page 2 of 4
CDP File Number 238500 - 1
County ID Number: 5778177298
NEMA 4X Box or Equivalent
❑
Yes
❑
NO
Installer:
Brian McDaniel
Box 12 inches Above Grade
❑
Yes
❑
NO
1118 1
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
El
Yes
ElNo
❑Approved
❑ Disapproved
Alarm Visible
El
Yes
ElNO
2325 - Mitchell, Brittany
*Operation Permit completed by:
Authorized State Agent:&A-Al���Vlt—c"—Date of Issue: 0 5/ 1 0/.1 0 1 7
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 111 G. sewage septic system.
Rule .1961 requires that a Type TYPE 111 G. septic system meet the following criteria:
Minimum System Review By The Local Health Department: N/A
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency By Certified Operator:
N/A
Reporting Frequency By Certified Operator: N/A
Rule .1961 requires that a Type IV and V septic systems designed for a home/business 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 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.
9 Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 3of4
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC
Drawing Drawing Type: Operation Permit
CDP File Number: 238500 - 1
County File Number: 5778177298
27028 Date: / /
O Inch
Scale: O Block
O N/A
Page 4 of 4 P1 P2 P3
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC
CDP File Number:
27028 County File Number:
Date:. . /
Click below to import an image from an external location: Drawing Type: Operation Permit
5778177298
Page 4 of 4 P1 P2 P3
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Septic Tank:
Pump Tank:
Supply Line:
Pump Requirements:
Electrical Equipment:
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