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317 Cornwallis Drive Lot 23 OPERATION PERMIT or fice use Unly Davie County Health Department *CDP File Number 139817- 1 r5�0 Q 210 Hospital Street 1 P.O. Box 848 County ID Number: Mocksville NC 27028 Evaluated For: EXPANSION Phone:336-753-6780 Fax: 336-753-1680 Township: Applicant: Howard Price Property Owner: Howard Price Address: 4509 Zack Road Address: 4509 Zack Road City: Monroe City: Monroe State2ip: NC 28110 State2ip: NC 28110 Phone#: (336)635-8595 Phone#: (336)635-8595 Property Location & Site Information rAddress/Road#: Subdivision: Pudding Ridge Phase: Lot: 23 317 Cornwallis Drive Mocksville NC 27028 Directions Structure: SINGLE FAMILY i-40 Exit Farmington Rd. turn left Pudding Ridge on left. #of Bedrooms: 4 #of People: 'Water Supply: PUBLIC "System Classification/Description: *IP Issued by. 2140-Nations,Robert TYPE IIA.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140-Nations,Robert Saprolite System? OYes QNo Design Flow: 4 8 0 "Distribution Type: GRAVITY-SERIAL Pump Required? OYes (DNo Soil Applicatan Rate: 0 a 7 5 *Pre-Treatment: Drain field Nitrification Field 4 8 0 Sq. ft. *System Type: INFILTRATOR QUICK 4 STANDARD No. Drain Lines a Installer: Randy Miller Total Trench Length: 1 a 0 ft Certification#: acin 9 Inches O.C. Trench S p g� — Feet O.C. *EH S: 2140-Nations.Robert Trench Width: — 3 Inches Feet Date: 0 8 / 2 9 / 2 0 1 4 Aggregate Depth: inches Minimum Trench Depth: 4 8 Inches Minimum Soil Cover. 3 6Inches Approval Status Maximum Trench Depth: 4 8 Inches ELI proved❑ Disapproved Maximum Soil Cover: 3 6 Inches CDP File Number 139817 - 1 County ID Number: Septic Tank Manufacturer. t Lat. Long: STB: Gallons: Installer: Date: / / Certification#: 'EH S: "Filter Brand: ST Marker: ❑ Yes ❑ NO Date: Reinforced Tank: ❑ Yes ❑ No Approval Status 1 Piece Tank: ❑ Yes ❑ No ❑ Approved ❑ Disapproved Pump Tank Manufacturer. Installer: PT: Certification#: Gallons: 'EHS: Date: / / Date: Riser Sealed ❑ Yes ❑ NO Riser Height: ❑ Yes ❑ NO (Min.6 in.) Approval Status Reinforced Tank: ❑ YeS ❑ No ❑ Approved❑ Disapproved 1 Piece Tank: ❑ Yes ❑ No Supply Line Pipe Size: inch diameter Installer: Pipe Length: feet Certification#: *Schedule: *EH S: Pressure Rated ❑ Yes ❑ NO Date: Approved fittings ❑ Yes ❑ NO Approval Status ❑ Approved❑ Disapproved Pump r Pump Type: Installer: sing 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 ❑ NO CDP File Number 139817 - 1 County ID Number: i Electric Equipment NEMA 4X Box or Equivalent ❑ Yes ❑ NO Installer: Box 12 inches Above Grade ❑ Yes ❑ NO Certification 9: Box Adj.To Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ NO *EH S: Pump Manually Operable ❑ Yes ❑ NO *Activation Method: Date: Alarm Audible 01 Yes ❑ No Approval Status Alarm Visible ❑ Yes ❑ No ElApproved❑ Disapproved 2140-Nations,Robert *Operation Permit completed by: Authorized State Agent: e 01 Date of Issue: 0 8 / a 9 / a 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 II A. sewage septic system. Rule .1961 requires that a Type TYPE II A. septic system meet the following criteria: Minimum System Review By The Local Health Department: NIA 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 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. OHand Drawing Olmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT 139817 - 1 Davie•CountyHealth Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: Olnch Drawing Drawing Type: Operation Permit Scale: . OBlock ON/A t1lij , t w kq i i U � CONSTRUCTION For office use only AUTHORIZATION "CDP File Number 139817-1 Davie County Health Department County ID Number: 210 Hospital Street Evaluated For: EXPANSION P.O. Box 848 •o.,...•• Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone:336-753-6780 Fax: 336-753-1680 0 7 / 1 7 a 0 1 9 Applicant: Howard PriceProperty Owner: Howard Price Address: 4509 Zack Road Address: 4509 Zack Road City: Monroe I Cay: Monroe State/Zip: NC 28110 State2ip: NC 28110 Phone#: (336)635-8595 Phone#: (336)635-8595 Property Location & Site Information Address/Road #: Subdivision: Pudding Ridge Phase: Lot: 23 317 Cornwallis Drive Mocksville NC 27028 Directions Structure: SINGLE FAMILY i-40 Exit Farmington Rd. turn left Pudding Ridge on left. #of Bedrooms: 4 #of People: *Water Supply: PUBLIC System Specifications Minimum Trench Depth: a 4 r ication: Provisionally Suitable Inches Minimum Soil Cover.stem? OYes ®No 1 a Inches : 4 8 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 a 7 5 Maximum Soil Cover: a 4 Inches *System Classification/Description: *Distribution Type: GRAVITY-SERIAL 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: OYes @No Pump Required: OYes @No OMay Be Required Nitrification Field 4 8 0 Sq. ft. Pump Tank: Gallons No. Drain Lines a 1-Piece: OYes ONo Total Trench Length: 1 a 0 ft GPM—vs— ft. TDH Trench Spacing: — 9 Onches O.C. Dosing Volume: _ Gallons Feet O.C. Trench Width: — 3 . 2inches Feet Grease Trap: Gallons Aggregate Depth: - inches Pre-Treatment: O N SF OTS-1 O TS-II Septic Tank Installer Grade Level Required: 01 011 0111 OIV CDP File Number 139817 - 1 County ID Number: ❑ Open Pump System Sheet Repair System Required:@Yes ONo ONo, but has Available Space rDesign System Inches O.C. Trench Spacing: 2 ification: Provisionally Suitable 9 Feet O.C. Trench Width: Q Inches w: 4 8 0 — 3 @ Feet Aggregate Depth: Soil Application Rate: 0 a 5 inches -- __ Minimum Trench Depth: a 4 'System Classification/Description: Inches TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. 1 a Inches 'Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: a 4 Inches_ Nitrification Field 1 9 a 0 Sq. ft. No. Drain Lines 4 'Distribution Type: GRAVITY-SERIAL Total Trench Length: 4 8 0 ftPump Required: Oyes jNo 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. �« 7', '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. 2( 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 sametime 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 perm It or ConstrucWn 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: 2140-Nations,Robert Date of Issue: 0 7 1 7 a 0 1 4 Authorized State Agent: �, —z- -- Malfunction Log Oyes Hand Drawing'Olrnport Drawing **Site Plan/Drawing attached.** Pana 9 of APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie CountyEnvironmental Health 1 , PAID P.O.Box 848/210 Hospital Street CEe V�D tib; '7_` Mocksville,NC 27028 JUL by. (336)753-6780/Fax(336)753-1680 DC 2014 IMIY#dApplication For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑� LT Type of Application: ❑New System ❑Repair to Existing System XExpansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name _�4 c cwS A R- PC-;.re- Contact Person 140W A R,p ?f:C-06 Address 45091 Z A C.K R ucx cl Home Phone I-3 L-(.3 5'--ir55 5` City/State/ZIP My*4 2a a IJ.0 -Z Trl 16 Business Phone %m- 45 V ee.e I Email O h p l 192&@ S rrN t I . Co--.- Name on PermitlATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name (—1 6W F*a-o ?r;C.e Phone Number 4 Q - 3 D. Owner's Address 4S41 q 2 AC.K !&0 A e City/State/Zip Matt jna�r--i M.C. ZT-it o Property AddressS 1:2 Car N w A(l ► 5 Z)y-, City M a e-k S•J i 1(2 .11,C. Lot Size t, -0 It Tax PIN# S7aLr1b`Z 2G6- Subdivision Name(if applicable) �tx.n r� ..�c R:caa e. Section/Lot# a3 r Directions To Site: T A0.�n.�w.r t�,n. Q�-ty l�.ir�elt i�... R'e�e a lza,(Lm ue g ) L.g� orvL� Specify Problem Occurring: `` iJ-e<,o t o c.KA t,S-e- SJ-�z•r rY` `� �r-aw. •3 6 e.4 Z iz.-C—k o IF RESIDENCE FILL OUT THE BOX BELOW # People #Bedrooms Ar #Bathrooms Garden Tub/Whirlpool&es []No Basement: ❑Yes 5�rNo Basement Plumbing: ❑Yes RNo 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 system requested: Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: County/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes *0 If yes,what type? This is to certify that the information provided on 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 laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or stakinouse/facili 1 c ion,fro osed well location and the location of any other amenities. \ Site Revisit Charge Property owner's or owners legal representative signature d • Date(s): Client Notification Date: Date �p / V' EHS: S E�xP � b Sign given ❑Yes ❑No C 4 saP���,� Account# Revised 11/06 .SmC�tI i Invoice# DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT PERMIT and OPERATION PERMIT IMPROVEMENT PERMIT S/ 7 **NOTE** This improvement permit DOES NOT"authorize the construction or installation of a septic tank system or any wastewater system. AN AUTHORI2ATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit. (In compliance with Article I1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NAS PROPERTY ADDRESS It e7 � DATE / --Co j-n-Ala- SUBDIVISION Ala f/�s .Or-�. ry LOCRTION GI i C SUBDIVISION NAME ���//�/%✓� /ti'.= P LOT NUMBER oma, SEC./BLOCK NUMBER f RESIDENTAL SPECIFICATION: BUILDING TYPE &jfTe # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE �d _ TYPE WATER SUPPLY L DESIGN WASTEWATER FLOW (GPD) !�_ NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE f�7Dt� GAL. PUMP TANK GAL. TRENCH WIDTH s��� ROCK DEPTH " LINEAR FT. � OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: ***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. r - IMPROVEMENT PERMIT BYifl **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M. OR,1:00-1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760. OPERATION PERMIT SYSTEM INSTALLED BY r a� G� t NSU AUTHORIZATION N0. (�.3 OPERATION PERMIT BY DATE **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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. DCHD 10/95 6 Y Davie cCounty Health'Department ENVIRONMENTAL HEALTH SECTION D: Box 665: Mocksville, N.C. 27028 —�l7 )/L AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION d � (Issued in compliance with Article 11 of B.S. Chapter 130A, Wastewater Systems) ***This Authorization For Wastewater System Construction must be issued by the Davie County Environmental Health Section prior to issuance of any Building permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building'Persits.*** / AUTHORIZATION NUMBER NAME _ Firs't /i1/�//�P� DATE /C��,?D/.(?S� N2 NAME ON IMPROVEMENT PERMIT (If different than above) SITE LOCATION Z L2 COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM **WICE*** THIS AUTHORIZATION FD 5TEWATER 5V5TEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE DCHD 10/95 . i APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT w Davie County Health Department ¢: Environmental Health Section I. P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested B a'13 , ` C� Mailing Address Home Phone/� { Business Phone 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation ❑Septic Tank Installation Permit 4. System to Serve: ©-House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ try ❑ Other ❑ Unknown r,vw�c(,'s 023 l' 5. If house, mobile home: Subdivision Section Lot # 10 ❑ Basement/Plumbing € No. of People ❑ Basement/No Plumbing j. No. of Bedrooms I L�--Washing Machine No. of Bathrooms 9N a-- Dishwasher Dwelling Dimensions �'7 ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type } i No. of People Served No. of Sinks No. of Commodes 3 No. of Urinals No. of Lavatories No. of Water Coolers i. No. of Showers Water Usage Figures 7. Type of water supply: U-Pd is ❑ Private ❑ Community 8. Property Dimensions IACI Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No If yes, what type? 1 1 t l '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. f, r PROPERTY INFORMATION REQUIRED: , Directions to Property: Tax Office PIN /6 S' '• Road Name cof-AIWA(Lly "Drill-e Box #^(if available) City r i I I t i z p This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges i incurred from this application. DATE 1 NATU E j CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 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 ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD(1193) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME �/`��� DATE EVALUATED ADDRESS PROPERTY SIZE /AC PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well 11� Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 3 4 Lands-cape position Slope % ` HORIZON I DEPTH Texture group Consistence Structure MineralogX HORIZON II DEPTH Texture groupG Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE , SITE CLASSIFICATION: EVALUATED BY: LANG-TERM ACCEPTANCE RATOTHERS) PRESENT: REMARKS: e e 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 Moist VFR-Very 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 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 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