174 Ashburton Drive Lot 19OPERATION PERMIT
Davie County Health Department
210 Hospital Street
f
P.O. Box 848
=w'Mocksville NC 27028
Phone: 336-753.6780 Fax: 336-753-1680
Applicant: Shannon Freeman
Address: 174 Ashburton Road
City: Advance
StatefLip: NC 27028
Phone #: (336) 266-7447
*CDP File Number 137334-1
County ID Number:
Evaluated For: EXPANSION
Township:
%Property owner: Shannon Freeman
Address: 174 Ashburton Road
City: Advance
StatefLip: NC 27028
',Phone #: (336) 266.7447
Property Location & Site information
Address/Road #: Subdivision: Greenwood Lankes Phase: Lot: 19
174 Ashburton Road
Advance NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 5
# of People:
"Water Supply: PUBLIC
*IP Issued by.
*CA issued by: 2140 - Nations, Robert
Design Flow: 6 0 0
Soil Application Rate: 0 a 7 5
Nitrification Field
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Aggregate Depth:
Directions
Hwy 158 East right on Hwy 801 left on Underpass Rd
*System Classification/Description:
TYPE 11 A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
SaproliteSystem? QYes @No
'Distribution Type: GRAVITY- PARALLEL (eq. d -box) Pump Required?
QYes _ONo
*Pre Treatment:
Drain field
4 3 6 Sq. It.
1
1 0 9 ft.
— 9 Inches O.C.
Feet O.C.
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: Rnady Miler
Certification #: 1128
' EH S: 21140 -Nations, Robert
Date: 0 5/ a a/ a 0 1 4
Inches
Inches Approval Status
Inches [E Approved 0 Disapproved
Inches
CDP Fite Number 137334 -,1
Manufacturer. shoal
STB: 760
Gallons: 1000
Date:
0
4
1/
1
9/
2 0 1 4
*Filter Brand:
POLYLOK PL -122 With Pipe Adapter
ST Marker.
❑
Yes
M
No
Reinforced Tank:
❑
Yes
R
No
1 Piece Tank:
❑
Yes
El
No
Manufacturer
PT:
Gallons:
County ID Number:
Lat.
Long:
Installer: Randy Miller
Certification #: 1128
*EH S. 2140 -Nations, Robert
0
Date: 0 5/ 2 a/ a 0 1 4
Approval Status
® Approved ❑ Disapprovedf
Pump Tank
Date:
RiserSealed ❑
Yes
❑
No
Riser Height: ❑
Yes
❑
No (Min.6 in.)
Reinforced Tank: ❑
Yes
❑
No
1 Piece Tank: ❑
Yes
❑
No
❑ Approved ❑ Disapproved
Vent Hole ❑ Yes
Anti -siphon Hole ❑ Yes
e
Pipe Size:
inch diameter
Pipe Length:
feet
*Schedule:
Pressure Rated ❑
Yes
❑
No
Approved fiittings ❑
Yes
❑
No
Installer.
Certification #:
*EH S:
Date:
Date:
Approval Status
❑ Approved ❑ Disapproved
/ Pump Type: Installer.
(/ Dosing Volume: — Gal Certification
Draw Down: *EHS:
Inches
*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
Anti -siphon Hole ❑ Yes
❑
❑
No
No
CDP File Number 137334 -1
Electric Equi
County ID Number:
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 *EHS:
Pump Manually Operable
❑ Yes
❑
No
*Activation Method:
Date:
Alarm Audible ❑ Yes
Alarm Visible ❑ Yes
*Operation Permit completed by.
Authorized State Agent.
Owner/Applicant Signature:
❑ N0 Approval Status
❑ Approved ❑ disapproved
❑ No
2140 • Nations, Robert
Date of Issue: 0 5 l a a l 2 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; n A. sewage septic system.
Rule .1961 requires that a Type TYPE n X septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: WA
_ 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 ownerand 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.
G)Hand Drawing (Import Drawing
**Site Pian/Drawing attached.**
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC
Drawin2 Drawing Type: Operation Permit
CDP File Number: 137334-1 '
County File Number:
27028 Date:
Q Inch
Scale: OBlock
ON/A
r�o
Applicant:
Address:
CONSTRUCTION For office Use Only
AUTHORIZATION EMAILED 'CDP File Number 137334-1
Davie County Health Department County ID Number:
210 Hospital Street Dav.. Evaluated For: EXPANSION
P.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone: 336-753-6780 Fax: 336-753-1680 0 4/ 1 1/.1 0 1 9
Shannon Freeman Property Owner: Shannon Freeman
174 Ashburton Road Address: 174 Ashburton Road
City: Advance City: Advance
State2ip: NC 27028 State/Zip: NC 27028
Phone #: (336) 266-7447
m
i
Address/Road #:
174 Ashburton Road
Advance NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 5
# of People:
'Water Supply: PUBLIC
Phone #: (336) 266-7447
Subdivision: Greenwood Lankes Phase: Lot: 19
Directions
Hwy 158 East right on Hwy 801 left on Underpass Rd
System Specifications
Pagel of 3
Minimum Trench Depth:
a 4
Site Classification: Provisionally Suitable
N trification Field
4 3
Inches
Sq. ft.
Minimum Soil Cover
1 a
1
Saprolite System? OYes QNo
1 -Piece: OYes QNo
Inches
Design Flow: 6 0 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 - PARALLEL (eq. d -box)
TYPE III A. CONV SYSTEM > 480 GPD (EXCLUDING SFD)
Septic Tank:
—
1
0 0 0 Gallons
'Proposed System: 25% REDUCTION
1 -Piece:
OYes
QNo
Pagel of 3
Pump Required: OYes QNo OMay Be Required
N trification Field
4 3
6
Sq. ft.
Pump Tank: Gallons
No. Drain Lines
1
1 -Piece: OYes QNo
Total Trench Length:
1 0 9 ft
GPM—vs— ft. TDH
Trench Spacing:9
8Feet
Inches O.C.—
O.C.
Dosin Volume: Gallons
g
Trench Width:
3
8Feet
Inches
—
Grease Trap: Gallons
Aggregate Depth:
inches
Pre Treatment: ONSF OTS -1 OTS -II /
Septic Tank Installer Grade Level Required: 01 011 0111 OIV
Pagel of 3
CDP Fi)e Number 137334-1 County ID Number:
❑ Open Pump System Sheet
Repair System Required:OYes ONo ONo, but has Available Space
/Repair System
*Site Classification: Provisionally Suitable
Design Flow: 6 0 0
Soil Application Rate: 0 a 7 5
'System Classification/Description:
TYPE III B. SYSTEM W/SINGLE EFFLUENT PUMP
*Proposed System: 25% REDUCTION
Nitrification Field
No. Drain Lines
Total Trench Length:
a 7 8 a Sq. ft.
6
5
4
5 ft.
Trench Spacing:_
Inches 0.
8Feet
9 O.C.
Trench Width:
0 Inches
30 Feet
Aggregate Depth:
inches
Minimum Trench Depth:
a
4
Inches
Minimum Soil Cover.
1
a
Inches
Maximum Trench Depth:
3
6
Inches
Maximum Soil Cover:
a
4
Inches
*Distribution Type:
Pump Required: (Dyes 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.
7!
'Permit Conditions
The issuance of this permit bythe Health Department in no wayguarantees 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 maybe 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 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: 2140 -Nations, Robert
pj� Date of Issue: 0 4/ 1 1/ a 0 1 4
Authorized State Agent: ;!, e% �� Malfunction Log Oyes
QHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC
Davie County Environmental` Health
P.O. Box 848/210 Hospital Street AM
Dc:Mocksville, NC 27028 �-
1 7
(336)753-6780/ Fax (336)753-4680 U P f "t1 D 7
° ,
Application For: o Site Evaluation/improvement Permit o Authf�rization To Construct (ATC) o Both
Type of Application: oNew System oRe air to ExistingSystem �Ex ansion/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 L
Address
Contact Person G 'l alt n 6YPP 6 -al)
Home Phone .3-f 'iii Lt"1
usiness Phone
Email A 1,
Name on Permit/ATC if Differen han Above
Mailing Address City/State/Zip
PKUPEKI'Y 1NFUKMAIIUN *Date House/Facility Corners.hlaggect
NOTE: A survey plat or site plan must accompany this application. Included: o Site Plan oPlat(to scale)
(Permit is valid for 60 months with site plan, no expiration with complete plat.)
Owner's Name Q.tn l- Pho aNumber 3lr-DW,rfi'i-(q l
Owner's Address I 1-1Q +A,4110k..s 1,0n ►L 6 City/State/Zip L, 'inti ik�(- xl J bcp
Property Address City
Lot Size I Tax PIN# , r _ 4
N
Subdivision ame(ifapplicable) 1 -("i -t` 1G► (p(".GC V&_XJCJ iSection/Lot# 10)
Directions To Site:
Specify Problem Occurring: am Ml+ T
UV t<b
IF RESIDENCE FILL OUT THE BOX BELOW
# People # Bedrooms I— # Bathrooms Garden Tub/Whirlpool oYes oNo
Basement: oYes oNo Basement Plumbing: oYes oNo
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: oConventional oAccepted olnnovative oAlternative oOther.
Water Supply Type: o County/City Water o New Well oExisting Well o Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? o Yes oNo
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 undex to hat fam responsible for the proper identification and labeling of property lines and corners and
to 'n and flagging s lying the house/facility location, proposed well location and the location of any other amenities.
c I, Site Revisit Charge
ope owner' oro nees legal representative signature
Lf Date(s):
� Client Notification Date:
Date 10-7
3-7 32 [ G EHS:
uAvrc 9.;UUr41Y HLALltf DEPARTMENT ?
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION -
`NOTE:EIssued In Compliance with G.S. of North Carolina Chapter 130 Article 13c
S ge Treai ent and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number ;
Name —�` Date 4101 ,
Location -
/W AAl7r���_ct�sC�� s
Subdivision Name Lot No.� Sec. or Block No. T ) N
Lot Size House, Mobile Home Business Speculation
No. Bedrooms f� No. Baths _.,, _ No. in Family t
Garbage Disposal YES 1] NOR
Specifications for System:
Auto Dish Washer YES NO ❑ ��}/ �' t < ; S
Auto Wash Machine YES NO ❑ /Gd���
r•.:
Type Water Supply �—
'This permit Vold If sewage system described below Is not installed within 36 months from date of issue.
�. :....� . • i
;r
Improvements permit by
`C066ct a representative`of-the Da oun ealth Department for final Inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. or�iay b \ e ' Telephone Number. 704-634-5985. .i
7.3
Final Installation Diagram: iSystem installed by i' �' �/• �i s
' J
ry
1
Certificate of Completion Date—
'The
ate
'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.
APPLICANT INFORMATION
Account #:
Billed To:
Reference Name:
Proposed Facility:
Water Supply:
Evaluation By:
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
PROPERTY INFORMATION
Tax PIN/EH #: -
Subdivision Info:
Location/Address:
Property Size: Date Evaluated:
On -Site Well Community
Auger Boring Pit
i,
Public
Cut
FACTORS 1 2 3 4 5 6 7
Landscape position !L—
Slope
LSlope % 2
HORIZON I DEPTH
Texture group C
Consistence
Structure
Mineralogys
HORIZON H DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence i
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE n ?
SITE CLASSIFICATION: i S
LONG-TERM ACCEPTANCE RATE:
NIATSEV" .
Landscape I-osition oe
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
EVALUATION BY:
OTHER(S) PRESENT: e� ®�I C f
Moist
VFR - Very friable FR - Friable FI -.Firm VFI - Very firm EF! - Extremely firm
3
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
lYQtes ,
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 Lone -term accentance rate - ual/dav/ft2 nrlurn nvnrl tu.";—AN
Davie County, NC Tax Parcel Report Thursday, January 5, 2017
Parcel Number:
NCPIN Number:
Account Number:
Listed Owner 1:
Mailing Address 1:
City:
State:
Zip Code:
Legal Description:
Assessed Acreage:
Deed Date:
Deed Book / Page:
Plat Book:
Plat Page:
Building Value:
WARN 11N '1'tt1515 NUT A NUKVEY
Parcel Information
E8070B0008 Township: Shady Grove
5871962125 Municipality:
8305337 Census Tract: 37059-803
NORRIS HAYDEN Voting Precinct: EAST SHADY GROVE
174 ASHBURTON DRIVE Planning Jurisdiction: Davie County
ADVANCE Zoning Class: DAVIE COUNTY R-20
NC Zoning Overlay:
27006 Voluntary Ag. District:
LOT 19 GREENWOOD LAKE Fire Response District:
Land Value:
Total Assessed Value:
1.15 Elementary School Zone:
8/2015 Middle School Zone:
009961010 Soil Types:
0003 Flood Zone:
053 Watershed Overlay:
Outbuilding & Extra
Freatures Value:
Total Market Value:
ADVANCE
SHADY GROVE
WILLIAM ELLIS
GnB2,GnC2
DAVIE COUNTY
No
! [- 91'wv.�tr` I All data Is provided as Is without warranty or guarantee of any Idnd either expressed or Implied Including but not limited to the
iDavie County, implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the
Counor arising out of the use or lira, oto use the GIS dates, contractors or b this webite. employees from any and all claims or causes of action due to
Hopp -tom NC sig inability agents,P y t
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested
2. Address Os
el
3. Property Owner if Different than Above
Address
lN2�tlS1d✓c/—.iALi1a. /I/
Home Phone 9/,%—
Business Phone FI9-973-,A61i
4. Permit To: a) Installer Alter Repair
b) Privy Conventionally Other Type
Ground Absorption Q
c) Sub -Division 6,PEWWQdb,1t.&Sec ? Lot No.
5. System used to serve what type facility: House Mobile Home Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 4,K X Y6�'
Bed Rooms Bath Rooms '3 Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc
Estimate amount of waste daily (24 hours
7. Number and type of water -using fixtures:
commodes 3 urinal
lavatory showers,
dishwasher sinks
8. a) Type water supply: Publics Private Community
b) Has the water supply system been approved? Yes✓ No
9. a) Property Dimensions �.o��/
garbage disposal
washing machine
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? A10
What type?
This is to certify that the information is correct to the best of my knowledge.
Date
Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: co'e=S�d/
�/ivvp�e ,4 s 7
DCHD (6-82)
_ o.. m ��r , . �•: �-.�.; Ate`` ..��. ,,,:,, .
•
ts,1,62
iso
.175
90
Vn
21
22
23
n 4F
20, 6 , J� pOA Q
�•ec /� ,
2CE
160
i6 HPOA vo
�l1 Q ✓ t 6` 13 .x'97
ss ?tea ✓` o l /O. No '
loo
a s L 572-
. .... � t - '�k, nom- , -J� V �' / O . 'i -(�J _ _.✓ •'.
6,PEENwo.
,�
�.
^ 2 i \
- �l,_,r - � , �_6 � � � , .� . - . G '•�� �b?%"�C'Gr Ili _ �. p � (. !�`. _ d' � iCV % '
r
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name_ Date���� o
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
Topography/ Landscape Position
S
S
S
eS. >
PS
PS
PS
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
(Pi
PS
PS
PS
`U
U
U
U
i) Soil Structure (12-36 in.)
S!
S
S
S
Clayey.Soils
PS
PS
PS
`-�
U
U
U
Soil Depth (inches)S
S
S
�PS
i
PS
PS
U
U
U
) Soil Drainage: Internal
S
S
S
S
)
�
PS
PS
PS
U'
U
U
U
External
S_
g
S
PS
S
PS
S
PS
fj
U
U
U
i) Restrictive Horizons
Available Space
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
►) Site Classification
U—UNSUITABLE S—SUITABLE PS— Provisionally Suitable
Recommendations/ Comments:
Described byTitle Date
SITE DIAGRAM
OCHD (6-62)