157 Citadel Road Lot 7Phone: (336) - 753 - 6780
Davie County Health Department
YX vironmental Health Section
P.O. Box 848
210 Hospital Street
Courier # : 09-40-06 1911
Mocksville, NC 27028
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Fax: (336) - 753-1680
Name: Phone Number `� 7 7 % (Home)
Mailing Address: ?>0C 'Dbve t- P1 (Work)
• ] r
I,� P a 4/� �C 2? 2-G Email AddressAv r,C 0- ��..y, Is (e— N_C,
Property Address: 1,5-7 /' / G t I? V-111<1
Please Fill In The Following Information About The EXISTING Facility: /J
Name System Installed Under: ��I��T i 1014
l"
(d Type.Of Facility: /lqUSe-
Date System Installed (Month/Date/Year): Number Of Bedrooms: Number Of People:
Is The Facility Currently Vacant? Yes — If Yes, For How Long?,
Any Known Problems? Yes 4S�,--2-If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: 0 0/ Number Of Bedrooms: Number of People
Pool Size: a 62 Garage Size: Other:
Requested B Date Requested:
For Environmental Health Office Use Only
Approved Disapproved
Comments:
Environmental Health Specialist Date:
*The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee
(extended or limited) that the on-site wastewater system will function properly for any given period of
Payment:') Cash Check Money Order #
Paid By:_
Account #:
Received By:
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OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant:
Scott Marion
Address:
4727 Farm Bell Ct.
City:
Winston-Salem
State/zip:
NC 27127
Phone #:
(336) 764-3131
Address/Road #:
9
157 Citadel Road
Mocksville
NC 27028
Structure:
SINGLE FAMILY
# of Bedrooms:
4
# of People:
4
'Water Supply:
PUBLIC
*IP Issued by.
*CA issued by: 2140 - Nations. Robert
Design Flow: 4 8 0
Soil Application Rate: 0 - 3
Nitrification Field
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Aggregate Depth:
Property Owner. Scott Marion
Address: 4727 Farm Bell Ct.
City: Winston-Salem
Statefzip: NC 27127
Phone #: (336) 764-3131
n
Subdivision: Charlestowne Grant Phase: Lot: 7
Directions
Hwy 601 North, left on Liberty Ch Rd. Left on Wagner
Rd. right on Citadel rd. Property on left
*System Classiroation/Descdption:
SaproliteSystem? Q) Yes 0 N o
*Distribution Type: PUMP TO GRAVITY Pump Required?
(3) Yes 0 N
*Pre Treatment:
1 6 0 0 Sq. It.
4
4 0 4 It.
()Inches O.G.
— Feet O.C.
3 Qlnches
(g)Feet
inches
Minimum Trench Depth: a
9
Inches
Minimum Soil Cover. 1
7
triches
Maximum Trench Depth: 3
6
Inches
,Maximum Soil Cover:
4
Inches
*System Type: INFILTRATOR QUICK 4 STANDARD
Installer: Brian McDaniel
Certification #:
* EH S: 2140- Nations. Robert
Date: 0 5/ 1 5/ 2 0 1 5
CDP Fite Number 138381 -1
Manufacturer. 11ho8f
STB:
760
Gallons:
1000
Dosing Volume:
Date: 1
Date:
0 1/
1 a/
a 0 1 5
'Filter Brand:
POLYLOK PL -122 With Pipe Adapter
ST Marker.
❑ Yes
®
No
nforced Tank:
❑ Yes
O
No
1 Piece Tank:
❑ Yes
®
No
County ID Number:
Let. r
Long:
Installer. Brian McDaniel
Certification #:
'EH S: 2140 - Nations, Robert
Date: 0 5/ 1 3 / a 0 1 5
Pump Tank
Manufacturer shoal' Installer Brian McDaniel
PT: 42
Gallons: 1250
Brian McDaniel
Dosing Volume:
Date: 1
a/
0 6/
a 0 1 4
RiserSealed Q
Yes
❑
No
RiserHeight: El
Yes
❑
No (Min.6 in.)
nforced Tank: ❑
Yes
®
No
1 Piece Tank: p
Yes
❑
No
Pipe Size: a inch diameter
Pipe Length: 1 7 a feet
'Schedule: 40
Pressure Rated ® Yes ❑ No
►pproved fittings O Yes ❑ No
Certification #:
THS: 2140 -Nations, Robed
Date: 0 5/ 1 3/.1 0 1 5
upply Line
Installer Brian McDaniel
Certification #:
" EH S:
Date: 0 5/ 1 3 / 2 0 1 5
Pump Type: Zoeler
/
Installer.
Brian McDaniel
Dosing Volume:
-
Gal Certification #:
Draw Down:
Inches
'EH S:
2140 -Nations, Robert
"Chain: ROPE
Date.
0 5/ 1 3 / a 0 1 5
Valves Accessible 0
Yes
❑
No
Flow Adjustment Valve O
Yes
❑
NO
check -valve ®Yes
❑
NO
Approval Status
PVC Unions ®
Yes
❑
No
�l Approvedi ❑ Dlsapprouiadi
Vent Hole ®Yes
El
No
. w ..nr
Anti -siphon Hole R
Yes
0
NO
CDP File Number 138381-1 ' County ID Number:
Electric EciulDment
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 13 Yes ❑ No
Alarm Visible ❑ Yes ❑ No
2140 - Nations. Robert
*Operation Permit completed by'
Authorized State Ag Date of Issue. 0 5/ 1 3/ a g 1 5
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 I8A .1904 et. Seq.,,and all conditions of the Improvement Permit and
Construction Authorization. This property is served by.a' Sewage septic system.
Rule .1961 requires that a Type septic system meet the following criteria:
Minimum System Review By The Local Health Department:
Management Entity:
Minimum System Inspection/Maintenance Frequency By Certified Operator:
Reporting Frequency By Certified Operator
Rule .1961 requires that a TYPe IV and V septic systems designed fora hometbusiness 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 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 fora system required to be maintained by a public, or pnvate 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 m effect for as long as the
system is in use, and other requirements for the,continued proper performance of the system.n shalt also bee condition of
the'Operation'Permit that subsequent owners`of the systems execute such a contract.
@)Hand Drawing Qlmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksvilie NC
Drawing Drawing Type: Operation Permit
CDP File Number: 138381 -1
County File Number:
27028 Date:
Olnch
Scale: OBlock
ON/A
Fit
do jrb
y �
i
001,
10
1-7
it
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I
'dONSTRUCTION
` AUTHORIZATION
Davie County Health Department
210 Hospital Street
u P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant:
Scott Marion
Address:
4727 Farm Bell Ct.
City:
Winston-Salem
State/Zip:
NC 27127
Phone #:
(336) 764-3131
PERMIT VALID UNTIL:
0 6/ a 0/ a 0 1 9
Property Owner: Scott Marion
Address:
4727 Farm Bell Ct.
Address/Road #:
Winston-Salem
157 Citadel Road
Mocksville
NC 27028
Structure:
SINGLE FAMILY
# of Bedrooms:
4
# of People:
4
*Water Supply:
PUBLIC
PERMIT VALID UNTIL:
0 6/ a 0/ a 0 1 9
Property Owner: Scott Marion
Address:
4727 Farm Bell Ct.
City:
Winston-Salem
State/Zip:
NC
Phone #:
(336) 764-3131
27127
Subdivision: Charlestowne Grant Phase: Lot: 7
Directions
Hwy 601 North, left on Liberty Ch Rd. Left on Wagner Rd.
right on Citadel rd. Property on left
\SiMinimum Trench Depth: 3 6
/Site
Inches
Classification:
Provisionally Suitable
Sa rolite System?
p y
(Yes ONo
Minimum Soil Cover:
4 0 Inches
Design Flow:
4 8 0
Maximum Trench Depth:
3 6 Inches
Soil Application Rate:
0 3
Maximum Soil Cover:
4 0 Inches
*System Classification/Description:
*Distribution Type:
PUMP TO GRAVITY
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:
O Yes ®No
Pump Required: O Yes
O No O May Be Required
Nitrification Field
1 6 0
0
Sq. ft. Pump Tank:
1 0 0 0 Gallons
No. Drain Lines
4
1 -Piece:
OYes ®No
Total Trench Length:
4 0 0
GPM --vs-- ft. TDH
ft
Trench Spacing:
_ 9
Inches O.C.
Feet O.C. Dosing Volume:
Gallons
Trench Width:
3
Olnches
®
Feet
_
Grease Trap:
Gallons
Aggregate Depth:
inches Pre -Treatment: O NSF OTS -1 OTS -II /
Septic Tank Installer Grade Level Required: 01011 O III 01V
Page 1 of 3
CDP File Number 1.38381 - 1
County ID Number:
❑ Open Pump System Sheet
Repair System Kequireo: VY T Us v IVU 1,J NV, Uut nas rwauar)IC Pace
*Site Classification: Provisionally Suitable
Design Flow: 4 8 0
Soil Application Rate: 0 3
*System Classification/Description:
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR
LESS)
*Proposed System: 25% REDUCTION
Nitrification Field 1 6 0 0
Sq. ft.
No. Drain Lines 4
Total Trench Length: 4 0 0
ft.
Trench Spacing: 9 O Inches O.
0 Feet O.C.
Trench Width:3 O Inches
® Feet
Aggregate Depth:
inches
Minimum Trench Depth:
3
6
Inches
Minimum Soil Cover:
a
4
Inches
Maximum Trench Depth:
4
0
Inches
Maximum Soil Cover:
a
8
Inches
*Distribution Type: PUMP TO GRAVITY
Pump Required: ®Yes ONo OMay Be Required
Pre -Treatment: O NSF 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. Remaining
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. R mfg
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 130A336(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(9)1. 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 6 / a 0 / a 0 1 4
Authorized State Agent: rill Malfunction Log OYes
® Hand Drawing OlmportDrawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Construction Authorization
CDP File Number: 138381 - 1
County File Number:
Date: 06 /a0/.2014
O Inch
Scale: O Block
O N/A
Page 3 of 3
P1 P2
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
CDP File Number: 138381 - 1
County File Number:
Date: A 6./ a 0/ a 0 14
Click below to import an image from an external location: Drawing Type: Construction Authorization
Page 3 of 3
P1 P2
kV�c,�ioh1 � 1 P
Y ." ('
c-�
APPLICATION FOR SITE EVALUAMMINWIMPROVEMENT PERMIT &
Davie County Environmental Health
�
� 4 P.O. Box 848/210 Hospital Street D$�:
�lMocksville, NC 27028 2U y
(336)753-6780/ Fax (336),753-1680
a ion For: ❑ Site Evaluation/improvement Permit ❑ Authorization To Construct(ATC) Both
Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/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 to be Billed Sr -CTT MARToN Contact Person 5(,VT7 M+AAr01-1
Billing Address =171 ''1 FAA -rpt isf u- GT Home Phone 331,
City/State/ZIP /VG ;xwx-7 Business Phone 31/,-
Name
1G-Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Comers Fla22ed
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 scn 7T r",0a r- i^l
Phone Number
Owner's Address 0A-7 F4rth 8y4L CT
City/State/Zip !✓1.✓sTON S�4A iM A ey C amara 7
Property Address Ler 7 e,,4.4 LII sry,,A1,F 6AANT
CitY inoc ks ui R. -
Lot Size 3 , z rr f}C.AZ 5 Tax PIN#
Subdivision Name(if applicable) C/fr+elAcr✓tivt' i✓T
Section/Lot#--7—
Directions To Site: 60/ eJ , 7-o xZ6,rere y e tL4veeif 40 v
4 F<F O.✓ P4 Erik?. 9440 j76 f/7- o"�
ez-r,ffOCL XCA Q
If the answer to any of the following questions is "yes", supporting documentation must be attached.
Are there any existing wastewater systems on the site?
El Yes 14No
Does the site contain jurisdictional wetlands?
❑YesVNo
Are there any easements or right-of-ways on the site?
❑Yes Flo
Is the site subject to approval by another public agency?
[]Yes P5No
Will wastewater other than domestic sewage be generated?
❑Yes PO
IF RESIDENCE FILL OUT THE BOX BELOW
# People V # Bedrooms J_ # Bathrooms I%. 5- Garden Tub/Whirlpool Yes ❑No
Basement: es ❑No Basement Plumbing: XYes ❑No
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
If yes, what type?
l\N0
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 staking the house/facility location, proposed well location and the location of any other amenities.
Property owner's or owner's legal representative signature
Date(s): Site Revisit Charge
Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account # 5�1
Revised 11/06 Invoice #
,j1065
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110
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s Printed:May 21, 2014
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 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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Health Department
Environmental Health Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336) 751-8760
***DWCRTANT*** THIS APPLICATION CANNOT 8E PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed Y,�/ Co,e �E GG_ Contact Person
Mailing Address �j Z /�TL-ErD6_E/ t�t� �Borne Phone 4q7- - 4-g/ O
City/State/ZIP Mock s v/L 4 , /V C-- Z 7C Zia/ Business Phone 427- -4 444 a
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: X Site Evaluation 0 Improvement Permit/ATC 0 Both
4. System to Service: XN House U Mobile Home 0 Business 0 Industry 0 Other
s. If Residence: # People # Bedrooms # Bathrooms
P Dishwasher 1.1 Garbage Disposal U Washing Machine 11 Basement/Plumbing 11 Basement/No Plumbing
6. If Business/Industry/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: County/City 11 Well U Community
e. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes 'KNo
If yes, what type?
"' IMPORTANT " CLIENTS AIUST CO3IPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN AIUST BESUBAIITTED by the client with THIS APPLICATION.
Property Dimensions: G • -5'4e--
Tax Office PIN: # !— — do 7�RITE DIRECTIONS (from Mocksville) to PROPERTY:
/ `,
Property Address: Road Name WACz,,VrP. ?,QR D ��/�
LeF-r o" Z"EL& 'N So 4m/ -e-
City/zip / e—<s1/le.e.E 27o Zr
If in a Subdivision provide information, as follows:
Name: (92"
f�� Bio
Section: Block: Lot:
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information
submitted in this application is falsified or changed. I, also, understand that I am responsiblejor all charges incurred from
this application. I, hereby, give consent to the Authorized Representative of the DpvicCount Health Department
to enter upon above described property located in, Davie County and owned by I ACD �• Cole�ft.G . :32L
to conduct all testing procedures as necessary to determine the site suitability. ,,��/
DATE t?'-- /� — 98' SIGNATURE.21�1 � Cly •+�-
DAVIE COUNTY HEALTH DEPARTMENT
- Environmental Health Section SECTION LOT
Soil/Site Evaluation
APPLICANT'S NAME Ii C�LI� DATE EVALUATED
PROPOSED FACILITY r , 17 sti PROPERTY SIZE ' X -S x 22 f q,53
SUBDIVISIONROADNAME j�AfJt21- r2t7
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
L
Sloe %
HORIZON I DEPTH
—to
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
0 -
Texture group
Consistence
R
Structure
A51c
Mineralogy1
HORIZON III DEPTH
-
Texture group
c i'
Consistence
Structure
A6 I -L
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Fr
Structure
k
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
ED
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: �' J� OTHER(S) PRESENT:
REMARKS:
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
oiA
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 (01-90)
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