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222 Hidden Valley Lane Lot 11i CONSTRUCTION AUTHORIZATION N Davie County Health Department 210 Hospital Street P.O. Box 848 T For Office Use Onlv *CDP File Number 194264-1 County ID Number. Evaluated For: HDR/WWC Township MOCkSVIlle NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax: 336-753-1680 0 6/ 1 6/ a 0 a 0 Applicant: Michael and Stacey Johnston Address: 222 Hidden Valley Lane City: Mocksville State2ip: NC 27028 Phone #: (336) 492-6429 LE Address/Road #: 222 Hidden Valley Lane Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 3 # of People: "Water Supply: EXISTING WELL Property Owner: Michael and Stacey Johnston Address: 222 Hidden Valley Lane City: Mocksville State2ip: NC 27028 Phone #: (336) 492-6429 Subdivision: Hidden Valley Phase: Lot: 12 Directions Hwy 601 North Left on Allen Rd. right on Hidden Valley EYTN Dflnn ! ^f 'A Minimum Trench Depth: a 4 \ Inches Site Classification: Provisionally Suitable Saprolite System? OYes @No Minimum Soil Cover. 1 a Inches Design Flow: 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 - PARALLEL (eq. d -box) TYPE It A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons "Proposed System: 25% REDUCTION 1 -Piece: OYes QNo Pump Required: OYes ®No OMay Be Required Nitrification Field 4 3 6 Sq. ft. Pump Tank: Gallons No. Drain Lines a 1 -Piece: OYes ONo Total Trench Length: 1 0 9 ft GPM—vs— ft. TDH Trench Spacing: _ 913 Inches O.C. Dosing Volume: Feet O.C. g _ Gallons Trench Width: 3 Inches _ . "Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS -1 OTS -11 Septic Tank Installer Grade Level Required: 01 J 011 0111 OIV Dflnn ! ^f 'A CDP File Number 194264 - 1 air *Site Classification: County ID Number: ired:OYes ONo ONo, but has Available S Design Flow: 4 8 0 Soil Application Rate: 0 - 2 7 5 ❑ Open Pump System Sheet Trench Spacing: — 9 Inches 0. Feet O.C. Trench Width: Inches 3 Feet Aggregate Depth: inches Minimum Trench Depth: 'I 4 *System Classification/Description: TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. 'Proposed System: 25% REDUCTION Nitrification Field 1 7 4 5 Sq. ft. No. Drain Lines 5 Total Trench Length: 4 3 6 g, 1a Maximum Trench Depth: 3 6 M S 'I C Inches Inches Inches axlmum of over. a 4 Inches *Distribution Type: GRAVITY- PARALLEL (eq. d -box) Pump Required: OYes @No 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. *Permit Conditions The issuance of this permit bythe Health Department in no wayguarantees the issuance of other permits. The permit holder is responsible forchecking with appropriate governing bodies in meeting their requirements. ; Thi Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit: not to seed five years, and maybe Issued at the same time the Improvement Penult issued (NCGS 130A-336(b)� If the installation has not been -,,wtompleted 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 Inwiid, and maybe suspended or revoked (.1937(g)). The person owning "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/ 1 7 1 a 0 1 5 Authorized State Agent- Malfunction Log OYes 01 -land Drawing Olmport 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 Drawing Drawing Type: Construction Authorization CDP File Number: 194264 - 1 County File Number: Date: 06/13/2015 Q Inch Scale: QBlock QN/A ......... ... . ........ . 1 �I i I II -- - --- - -- ------------ . .. ....... - III Ililll I ... .. ........ ....... . . . �F....... -------------- - ----- CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Sox 848 Mocksville NC 27028 CDP File Number: 194264 -11 County File Number: Date: 06/ 17 /2015 Click below to Import an image from an external location: Drawing Type: Construction Authorization HEALTH DEPARTMENT RELEASE Davie County Health Department 210 Hospital Street f . P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Michael and Stacey Johnston Address: 222 Hidden Valley Lane City: Mocksville State2ip: NC 27028 Phone#: (336) 492-6429 For Office Use Only *CDP Fife Number 194264-1 County ID Number. Evaluated For: HDR/WWC PERMIT VALID 0 5/ 0 4/ a 0 a 0 UNTIL: Property Owner: Michael and Stacey Johnston Address: 222 Hidden Valley Lane City: Mocksville State0p: NC Phone M (336) 492-6429 27028 Property Location & Site Information Address222 Hidden Valley Lane Subdivision: Hidden Valley Phase: Lot: 12 Road # Mocksville NC 27028 SINGLE FAMILY Township: 'Structure: Directions # of Bedrooms 3# of People: Hwy 601 North Left on Allen Rd. right on Hidden Valley *Water Supply: EXISTING WELL Basement: ❑ Yes FjNo Type of Business: Total sq. Footage: No. of Employees: 'Proposed Improvement: Replacing Home J v ' I�I(;ssur- ev-p4 simi pitp-mil Arz.6�ollZvrl s. �' This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps. Signature Required? oYes ONo Applicant/Legal Reps. Signature; *Issued By: 2140 -Nations, Robert Authorized State Agent: *Date: *Date of Issue: 0 6% 0 9/ a 0 1 5 **'Site Plan/Drawing attached.** @Hand Drawing almportDrawing _ r i Vk �, �LQ06 cs Davie County Health Department 036A.2;1JO, q i8 j Environmental Health Section pA►� 15 P.O. Box 848 f �D 210 Hospital Street I Courier # : 09-40-06 Mocksville, NC 27028 Phone: (336) - 753 - 6780 Fax: (336) - 753-1680 ON-SITE + WATER CERTIFICATION (Check One Replaceme Remodeling Reconnection Name: rn / C -} JQ 6 p. ,$ �(4 Phone Numbe 7 — (Home) Mailing Address:� eti t.��p�f1, �00 e Kj t/,, DL� C Email Address: ' Detailed irections To Site: tF &0/t Al L1941 A hf(1 41'Id Property Address: Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: Type Of Facility: &I# Date System Installed (Month/Date/Year): Number Of Bedrooms: 2 Number Of People: Any Known Problems? Yes (10 If Yes, Explain: Please Fill In The Following Information About The NEW Facility: � Type Of Facility: /�0 Number Of Bedrooms: -3 Number of People Pool Size: A Garage ize: Other: Requested By: Date Requested: For Environmental Health Office Use Only Approved Disapproved Comments: Environmental Health Specialist Date: *The signing bf 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 - ew system will function properly for any given period of time. Payment: Cash hec Money Order # / Amount:$ 11VU,1VU Date: 15 Paid By: q,,& Received By: Account #: I `'7�y 7Invoice #: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section II P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001323 Tax PIN/EH #: 5729-18-3736 Billed To: Michael & Stacey Johnston Subdivision Info: a l DDoJ VaLx,Ly ACUA(I � j rZ Reference Name: Location/Address: Hidden Valley Trail -27028 Proposed Facility: Residence Property Size: see map 22 **NOTES* ' i bfmprovemment/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHORIZATION 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 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type m 1+ #People .3 #Bedrooms — --2S #Baths -2- Dishwasher: Dishwasher: 03""" Garbage Disposal: ❑ Washing Machine: I]7� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specificationnn13__: Facility Type #People #People/Shift #Seats Industrial Waste: Lot Size _ EG ccMe Water Supply _]� Design Wastewater Flow (GPD) . Site: New Repair ❑ System Specifications: Tank Size 100l .JAL. Pump Tank GAL. Trench Width �� Rock Depth Z I Linear Ft. � Other: 2 QI STt2j &or icJ %r- -S Site Modifications/Conditions: lt,f, TpLL DrACa.3-iook ILa-p—P S; oFF ked 5y-�I 420m IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 u BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this syst between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:3 . .m.Don`�thee day of installation. Telephone # is (336)751-8760.**** 1. L2o,c .'7p'c�c. y L ISI. r-�ann.c. (J Si A g °� 3� -r Environmental Health Specialist's Signatur . Date: 1 J oD DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001323 Tax PIN/EH #: 5729-18-3736 Billed To: Michael & Stacey Johnston Subdivision Info: Reference Name: Location/Address: Hidden Valley Trail -27028 Proposed Facility: Residence Property Size: see map ATC Number: 2522 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment1�and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATEI�O J�A IS LLD OR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Date: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit 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. M VA _rb- -Gil Septic System Installed By: / L", l c�— Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) APPUCATION FOR SITE EVALUATION IMPROVEMENT PERMIT & ATC s ►� 5 Davie County Health Department Environmenta/Hes/th Sectfon P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 AUG 10Ta N ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Nass to be Billed M1 ha pl er\A mat t,,e , Salm%irrN Contact Person M�C_4�oP ( S n6hx� Hailing Address 0 -AZ la 9A\\2"'4 Q-oN Ck Homo phone 3?(0 - t l(n3 - N ae! city/state/ZIP tApc�V,1,,.i��� e1 n(` o?--oSS Business phone 331x-75 I- 3SLv( ko339S 2. Name on Permit/ATC if Different than Above Mailing Address C�ity/State/Zip 3. Application For: lite Evaluation 13`ty/Improvement Permit/ATC ❑ Both 4. system to Service: ❑ House g4bile Home ❑ Business 0 Industry 0 Other 5. If Residence: # People 3 # Bedrooms 3 # Bathrooms o2 Dishwasher n Garbage Disposal PrWashing Machine U Basement/Plvabing O Basement/No Plumbing S. If Business/Industry/Other: specify type # People # sinks # Commodes # shovers # Urinals # hater Coolers I.P 7001iZERilCE: # Seats Estimated slater Osage (gallons per day) 7. Type of water supply: ❑ County/City ii} *ell 0 Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes U -Ko If yes, what type? ***IMPORTANT*** CLIENTS MAST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. max.+) (sz (51b) i Lt 'M k, b2&, 73 / 54, Property Dimensions: S, S J J -I Sy a(g, 53 Y5i o.oS k (x WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office?IN: #Staq-18.7373b (oo( oor-4) kin IPFt-�n,4(lenZ4( gxs;cto Property Address: Road Name (k6Sen V n (i e v Trai ( ftvekj�k{gz�' expoo V. a- 3 0- k le s �s 2 AA City/Zip M, (' Ao.S u 1 w';' n [' If in a Subdivision provide information, as follows: Name: Section: Block: Lot: > a A(A-., C -I Aix -r% r%i qh I en l4-ic &A 0-g1liu Lk; -e 6Q6k ()F:kr 4(.r :rc,nF. c.IM 0 Date Property Flagged: Fc - 01- OD 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 responsible for all charges Incurred front this application. 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 the sitAsuditabi OA -1 E v 1 Q 0THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLoft the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). ^1 o- v L 0 WtO Revised DCHD (07/99) Site Revisit Charge 'Date(s): I Client Notification Date: I EHS-. Account No. vP Invoice No. (v 5 ................................ . DIRECTOR OF PLANNING AMOS S. BROWN DB. 11 PG, 115 162912 total) 338.55 �� ............�.. rte' ................ Su praal (Seal or Stamp) Rtg ' tration Number' ptac•4 ton ,.. u� wrrect dayo( ........................... 19 .................. This ....... ............. ...... day at..................................................19 ........'........ Probate fee paid. � Notary Public Heriry L, Shore, Register of Deeds by................................................ Seal or Stamp My commission expires ...I ............... DEPUTY - ASSISTANT V nm1 extst?ng kon ,y BILLY W. TRIVETTE _ J 0 o DB. 150 PG. 631 r k 3 v o AMOS S. BROVIN D8.11 F - G. 115 O V a N w .2 m � � CR o h I'1 Q " AREA = 5,130 ACRES Z tp O ra plac•E - - - J z r.i �� S 88. 52' 17" E ---- ( 955.68 total) O —"�- = 564:©5— — -----•v -- — 395.63 F i AREA _ 5.130 ACRES t 60' EASEMENT { AREA = 5.126 ACRES p a o 340.44 0 330.65 229.8_ V M V nm1 extst?ng kon ,y BILLY W. TRIVETTE _ J 0 o DB. 150 PG. 631 APPLICANT INFORMATION DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Account #: 990001323 Tax PIN/EH #: 5729-18-3736 Billed To: Michael & Stacey Johnston Subdivision Info: Reference Name: Location/Address: Hidden Valley Trail -27028 Proposed Facility: Residence Property Size: see map Date Evaluated: Water Supply: Evaluation By On -Site Well Auger Boring Community Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group 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: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: OTHER(S) PRESENT: 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 05/99 (Revised) APPUCATION FOR SITE EVAUJATION/IMPROVEMENT PERMIT & Davie County Health Department Environmental Healtfi Sbction P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed_d%esdr 1�/Yl/i Z.P.( L Mailing Address ��{7ja�i d Oy, City/state/ZIP i�.r' .�J �� �1/ �%/1"74��g 2. Name on Permit/ATC if Different than Above Nailing Address Contact Person „/jav" uj 7 ! OQ Home Phone # 72 Z Business Phone City/state/Zip 3. Application For: I'Site Evaluation 0 Improvement Permit/ATC 0 Both s. system to service: l/House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms ,3 # Bathrooms 2 (Dishwasher ❑ Garbage Disposal V1/Washing Machine fl Basement/Plumbing fl Basement/No Plumbing 6. If Business/Industry/Other: specify type # Commodes # showers IF FOODSERVICE: # Seats # People # sinks i Urinals i Water Coolers Estimated Water UsatJe (gallons per day) 7. Type of Water supply: Ujw— ❑ County/City R( Well B. Do you anticipate additions or expansions of the facility this system is intended to serve? If yes, what type? 0 Community 11 ❑ Yes Ya 0 ***I11fP0RTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: 1.3 cnP,aJ WRITE DIRECTIONS (from Mocksville) to PROPERTY: �3 `7F41OfiicePIN: #-2-r—J -1 a., Property Address: Road Name MaZ Z L0,&U, Ct4(R/ City/Zip (ffkC4 „r"Q'L &G, If in a Subdivision provide information, as follows: Name: ri Section: Block: Lot: 1:71 i P . / / & Date Property Flagged: 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 responsible for all charges incurred from this application. 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 the site suitability. DATE Jr' /0- /J O SIGNATURE .ems ,Y►� �,P� THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) Site Revisit Charge Date(s): Client Notification Date: EHS• ` Account No. per/ ��� Invoice No. BDIVISION PLAT APPROVAL 'l, ........ Grady,..l.,,,Tutterow ..................................................certify that this plat was drawn under my supervision from an actual survey made under my supervision (deed description Nort jai meets the recording requirements of the Subdivi• recorded in Book ........................................... .............. ........ ; Page .............,etc.) (offier), I, a Notary Public of the C Davi County and , if applicable, that a that the boundaries not surveyed are clearly Indicated as drawn from information found in .. been issued by the Division of Highways pursuant to w General Statutes. State of North Carolina Book ............................................. .Page _. _ .............. ... ; that the ratio of preclson as Surveyor, personally ap{ caladated is 1 :..................... _. .... 'That this plat was prepared in accordance wdh 6 S execution of the forugom, of _ _ ._ ._............ _......19 ............... . 4/ 70 as amended Wllness my original Signature, registration number and seal this Seal, this .... dayof ......... ......... ....._ ......__. A.0 , 19 _...... Surveyor ............. I ............................................................... ARECTOR OF PLANNING ( Seal or Stamp) Ileglstratuon Number:Seal or Stamp 4OS S. BF -..)WN DB. II P(�.115 1 829.12 tutal ) 338.55 140.57 plated Iron O _ AREA = 5.133 ACRES w v a .n r` m r � 0 Z 336.60 ( 1833.53 total ) O AREA = 5.133 ACRES 331.00 O AREA = 5.133 ACRES �q) AREA = 5.3, 3 ri v AMOS S. N N Gt7, 11 FG�;I� O 1I w � N AREA = 5.130 ACRES cli p placed J� 6 Z /5 •` Iron S 88' 52' 17" E 560.05 —' 12 , AREA w = 5,130 ACRES a N M x � N 2 —-.._------------o" — ---------- AREA=5.1'9 1 1896.89 iota) 34D.44 S• fib' J3" w N 39' LJ' '�'�\ } \ L'd" 1 V tV � 1 \ 6/• C to O _ AREA = 5.133 ACRES w v a .n r` m r � 0 Z 336.60 ( 1833.53 total ) O AREA = 5.133 ACRES 331.00 O AREA = 5.133 ACRES �q) AREA = 5.3, • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900214 Tax PIN/EH #: 5729-28-3456.12 Billed To: Eugene Bennett Subdivision Info: Hidden Valley Lot # 12 Reference Name: Eugene Bennett Location/Address: Hidden Valley Lane -27028 Proposed Facility: Residence Property Size: 5.13 Acres Date Evaluated: t i �oV Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope % 7 Cr HORIZON I DEPTH O - - p - Texture group CL_ Consistence F� S Structure G 531E lc Mineralogy l: HORIZON II DEPTH - it, Texture groupG Consistence F;5 Structure 1c Mineralogy ; HORIZON III DEPTH - 32-31, Texture group RFs -l' Consistence I C_r SP cr-6 r Structure I Mineralogy HORIZON IV DEPTH + Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: 16 7�'_ LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY:Lmakvp_ OTHER(S) PRESENT: x2i/U"_;� nJ 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 05/99 (Revised) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■.-ate■■■■■■■■■■i■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ire■■■■■■■■ ■■■■■■ ■■■■■■ ■■■■■■ ■■■■■■ ■■■■■■ ■■■■■■ ■■■■■■I ■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■jjj������������������������������iiiiiiiiiiiiiiiiiiiii��ii::::::: d�✓XO AUT„HORIZA�TION NO: 1,652 DAVIE COUNTY HEALTH DEPARTMENT environmental Health Section PROPERTY INFORMATION Permittee'~ P.O. Box 848 Name: " - ri / Mocksville, NC 27028 Subdivision Name: ` "li `-t' f-�'' �� VQlk-41 Phone # 336-751-8760�- Directions to property: AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Section: Lot: Tax Office PIN:# Road Lai. **NOTE** 05 f �'cti **NOTE** 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 Permits. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION _',� . ��� •% r /_.�-[s`fi d`;. J �"~,� IS VALID FOR A PERIOD OF FIVE YEARS. NVIRONMENTAL HEALTH SPECIALIST DATE ISSUED U DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Permit! e`'s Name: �, ��I � /,�.�J? Ci`�`? Subdivision Name: Directions to property:Section:_ IMPROVEMENT PERMIT Tax Office PIN:# `> Road Lot: **NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An AUTHORIZATION 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. On compliance with Article 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ✓'' a ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE �!, . ; l •' r'` s `,' PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER *"ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS —.2-- # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT / # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE �2 TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) J NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE�(2%b GAL. PUMP TANK GAL. TRENCH WIDTHS ROCK DEPTH,_ LINEAR FT. REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT illff tb�/1 l d Rf c S� �0" 0WCt/ "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 (336)751-8760. OPERATION PERMIT WN SYSTEM INSTALLED BY: AUTHORIZATION NO. _!�-.J— 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 05/96 (Revised) APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC Vq9 / Davie County Health Department Environmental Health Section P. O. Box 848 Mocksville, NC 27028 (704)634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Debbie 1. Name to be Billed Brent E Tomi)nr.lin Contact Person 634- 3591 Mailing Address 399 n. Ridge Road Home Phone 704-284-6135 City/State/Zip Mocksville, NC Business Phone 998-2121 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip �-4 erIm rovement Permit & ATC Ll Both 3. Application For: 2) Site Evaluation p 4. System to Serve: 0 House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People 2 # Bedrooms 3 # Bathrooms2 © Dishwasher ❑ Garbage Disposal ® Washing Machine ❑ Basement/Plumbing 5f Basement/No Plumbing 6. If Business/Other: Specify type # Commodes If Foodservice: 7. Type of water supply: # Showers # Seats ❑ County/City # People # Sinks # Urinals Estimated Water Usage (gallons per day) X] Well # Water Coolers 8. Do you anticipate additions or expansions of the facility this system is intended to serve? If yes, what type? ❑ Community ❑ Yes Pk No INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: �� 1 WRITE DIRECTIONS (from �} 1 Mocksville) TO PROPERTY: Tax Office PIN: # S%'9 - �d - `3vs— ( s ( 601 N. to Allen Rd Property Address: Road Name Hidden Va 1 1 _y Road 1 1 coo 1 1/2 Mile to City/Zip Mnc-kcvi 11 Pf Nr 1 1 Hidden Valley Rd. 1 If in Subdivision provide information, as follows: 1 1 First Lot on Right Name: 1 1 Old shed at entrarq 1 Section: Tract 12 Lot #: 1 1 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 responsible for all charges incurred from this application. 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 Brent Tnmherl i n to conduct all testing procedures as necessary to determine the site suitability. i�� DATE I ) — Q —C( �_ SIGNATURE a&JJCAL�- Revised DCHD (06-96) Z46c,7L 'Rd/ "OK ' .;?,R 0 DAVIE COUNTY HEALTH DEPARTMENT -Xfi cwt - Environmental Health Section SECTION +_� I a— APPLICANT'S NAME PROPOSED FACILITY SUBDIVISION Water Supply: On -Site Well Soil/Site Evaluation Community Evaluation By: Auger Boring Pit DATE EVALUATED PROPERTY SIZE ROAD NAME Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence i Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION j LONG-TERM ACCEPTANCE RATE 1 SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: DCHD (01-90) EVALUATION BY: A iv OTHER(S) PRESENT: 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 i ■ ■ NONE MO■■ ■ME■■■■■ ■■■M■■■■ ■■■MEMO■ ■■■■■■■■ ■■E■SSM■ ■■MEMS■■ ■SSS■■■■ ■■MME■■■ ■MM■■MM■ ■■M■MEM■ ■E■ME■■■ ■EMEMME■ ■E■■EMM■ ■ ■ ■ SOMME ■ENE■ ■■■E■ ■■E■■ ■■■11■■■ ■■■ SOM ■■■Sas■ ■■■SIS■■ ■NEVI■■■ ■■■11M■■ ■E■MEM■ ■■MIEN■■ ■EMEMM■ ■EREMEmi ■ERIMME■I MERIMMENI ■■11■■■ll ■ ■ ■ ■E■■■ MEMOS ■■■■■ MEMO MEMO NOME soon ■MEMMEMEM■EME■ ■■■■■■■■■■■■■M ■■■M■■■■■■■■■■ ■■■■■■■E■■■■■■ ■■■■■■■■■■■■■■ ■■■■■■■■■■■M■■ ■■■■■■■■■■■■■■ ■■■M■■■■M■■■■■ MMENM■■■E■■■■■ ■■MOO■M■M■■■■■ ■■SME■S■■■SE■■ ■■■■■■■■E■■■■■ ■MM■■M■E■■EM■■ ■■ME■■MEM■M■M■ ■EMMEM■■M■■M■■ ■E■E■■MEM■■EM■ ■■M■E■■M■■EM■■ ■EMMEMMEMEMEM■ ■M■MEM■MEM■M■■ ■E■E■MEM■MEMM■ ■M■■M■M■■■■■E■ ■ • SIDES S al FINAL SUBDIVISION PLAT APPROVAL This Is n deity tf W INs plat renes the rowrd ft requirement: a the subdlvi- see R/4slMeas /or • gnm t)rtbttivio wl on dm*a of IoM for fits conty of DOW Thisto »... _»_..».day of...»........................................»......19................. »_............ _»».«._».................. .............................. »»......... _................ »...... DIRECTOR OF PLANNING AMOS S. BROWN DB. II PG, IIS (82912 total) �v.vv 33&55- 1 ' r • X � ?IIACT q AREA = 5J30 ACRES M big •o A 0 W O01O N • �O� r 8 `e%s «IV UTILRI' EASEMENT 340.44 �r"•"» z ^mss «$---_---------- � '' % — — — — — — — — — — � ^°cw• • �10' UTIUTl� EASEMENT AREA'* 10.490 ACRES TERRY L CURRY DB, 177 PG. 74 %1 ,nAdT 9 I AREA a 5.133 ACRES 4.- v FB.00k ....�!!�»,.«.�......».:.........»....__».............arltatoDwae„my supsroision horn an atatel survey ittada under my superv4lort;deed descriptbn Tianh CaraFna .....»..........»»County r dad in Book ...».. »....................: Pape 731 »,ale.) (other): 1. a Notary Public of the County and State aforesaid, ce" that de bo ndan� nm a4lrveyed wade" indicated as drawn from infiimation bund in ..........�dX.»4»T1!n!!9!�... .».._...............s Repiswredland ,» ape : that the rat o of precision as Surveyor. personally appeared before me Qua day and aciUwwledged 1M c&,"ted is 1: DA(11fl » .»»: that this plat was prepared in aoctndance with G.S. execution of the l repoirq instrument. Witness my hand and official stamp or to be corna amended. "ss my oripstai signature. registration number ends" 11>s 13th seal. this ...............«................«. day of ...«.................. 19 TMs ....._..».»..A.�..19...9 ».. »........ fft 9". Notary Pubic N"e7 L .. 1 ( Seal a Stamp) Registration Number' Seal or Stamp w commission expires ... ...... � «..•, �„� 0 _ to 3 i el«•s r'err sift" t... � t asw mar l i -T AREIJS 33 ACRE' -AMOS •S. -BROWN D@. 11 PG. IIS bs� w �1JJ S 88.52' IT E — - 1 955.68 total ) 560.05 395.63 1 i1wACT 11 V k to SJ30 ACRES N MEN T _a — — _ — _F0' UPUTT EASEMENT MV= :a y 3 AREA a 3J26 ACRESrs on 6 ter+-•-�- M N• sr t7- w . � � _ _ --- - e; + in - - -�— _s• �\ c N /t ar •a• os- w�� W.00 \ \ M 396to':e- w�� `+ ��� 60 �^nv I• d u 'm11ACr 7 i I �» AREA = 5.133 ACRIcS. �Nr Ph S`` Nr� 1 � aE GniE ►w�te .......»... ............ � rKG��RSs��•— _. cwtN4 stj mssiOlJOO►11 w0 ................... rs ♦ C>00ft :T R'+� aSSrST1Nr Fled for registranc ............................ Plat Book ............ F&V Fee P ,3P D& ISO !& 631LLJ O a• IL _ -4 _ o Q t t10s1I9 sM� o 3227 0 t 5021 s z j, w �-€ see ^. wertts r«r 4.� I• d u 'm11ACr 7 i I �» AREA = 5.133 ACRIcS. �Nr Ph S`` Nr� 1 � aE GniE ►w�te .......»... ............ � rKG��RSs��•— _. cwtN4 stj mssiOlJOO►11 w0 ................... rs ♦ C>00ft :T R'+� aSSrST1Nr Fled for registranc ............................ Plat Book ............ F&V Fee P ,3P , -1 n o - D& ISO !& 631LLJ O a• _ Z _ Q t t10s1I9 sM� — 14 0?- a n 3227 155-rAs Md 1 �! — � _ 3.9 t 5021 , -1 n o - Davie County Health Department and Home Heafth Agency Environmenta(Heafd Section M P.O. BOX 848 / 210 HOSPffAL STREET ! COURIER #09-40-06 MOCKSVILLE, N.C. 27028 PHONE: (704) 634-8760 February 19, 1997 Brent E. Tomberlin 399 Pineridge Rd. Mocksville, KC 27028 Re: Site Evaluation Hidden Valley/Tract 12 Tax Office PIN: #5729'=28-3456 i Dear Mr. Tomberlin: As requested, a representative from this office visited the aforementioned site on February 18, 1997. Based upon the information provided on the application for site evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. If you have any questions, please feel free to contact this office. Sincerely, M W Robert B. Hall, Jr., R.S. Environmental Health Section RH/wd Enclosure(s) Davie County. NC Tax ParrPl R Pnnrt Tuesday, January 31, 2017 WARNING: THIS 1S NOT A SURVEY Parcel Information Parcel Number: G314OA0011 Township: Mocksville NCPIN Number: 5729187587 Municipality: NC Account Number: 82515141 Census Tract: 37059-806 Listed Owner 1: JOHNSTON MICHAEL Q Voting Precinct: NORTH MOCKSVILLE COUNTY Mailing Address 1: 222 HIDDEN VALLEY LANE Planning Jurisdiction: Davie County City: MOCKSVILLE Zoning Class: DAVIE COUNTY R -A State: Zip Code: Legal Description: Assessed Acreage: Deed Date: Deed Book / Page: Plat Book: Plat Page: Building Value: NC Zoning Overlay: 27028-5665 Voluntary Ag. District: No TRACT 11 HIDDEN VALLEY SECTION TWO Fire Response District: WILLIAM R. DAVIE 5.19 Elementary School Zone: WILLIAM R DAVIE Land Value: Total Assessed Value: 7/2000 Middle School Zone: NORTH DAVIE 003400897 Soil Types: ApB,WeC,PcC2,CeB2 0006 Flood Zone: 118 Watershed Overlay: DAVIE COUNTY Outbuilding 8r Extra Freatures Value: Total Market Value: Davie County, All data is provided as Is without warranty or guarantee of any Idnd 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 NC or arising out of the use or Inability to use the GIS data provided by this webstte. 1 OPERA ■ ION PERMIT Davie County Health Department 210 Hospital Street P.J. Box 848 •.,, > Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1580 Applicant: Michael and Stacey Johnston Address: 222 Hidden Valley Lane City: Mocksville State)Zip: NC 27028 Phone #: (336) 492-6429 Address/Road #: 222 Hidden Valley Lane Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: *Water Supply: EXISTING WELL *IP Issued by: 214© -Nations, Robert *CA issued by: 2140 -Nations, Robert rr i- or utrtce use unt *CDP File Number 194264-1 County ID Number. Evaluated For HDRIWWC Township: perty Owner: Michael and Stacey Johnston Address: 222 Hidden Valley Lane City: Mocksville StatefLip: NC 27028 Phone #: (336) 492-6429 ierty Location & Site Information Subdivision: Hidden Valley Phase: Lot: 12 Design Flow: 4 8 0 Soil Application Rate: 0 .2 7 5 Nitrification Field No. Drain Lines Total Trench Length Trench Spacing: Trench Width: Aggregate Depth: Directions Hwy 601 North Left on Allen Rd. right on Hidden Valley *System Classification [Description: TYPE 11A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Saprolite System? OYes @No *Distribution Type: GRAVITY- PARALLEL (eq. d -box) Pump Required? QYes QNo *Pre Treatment: Drain 4 3 6 Sq. ft. 1 1 0 9 ft. Qlnches O.C. 9 . eFeet O.C. ) Fetes inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. .1 4 Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: 4 Inches *System Type: INFILTRATOR QUICK 4 STANDARD Installer: Stephen Bryant Certification #: 1433 * EH S: 2140 - Nations, Robert Date: 0 3/ 0 7/.1 0 1 6 GDP File Number 194264 - I County ID Number: , ---I Manufacturer. STB: Gallons: Date: Dosing Volume: *Filter Brand: ST Marker: ❑ Yes ❑ No einforced Tank: ❑ Yes ❑ No , 1 Piece Tank: ❑ Yes ❑ No Let. Long: Installer Certification #: *EH S: Date: Pump Tank Manufacturer. Installer. PT: Gallons: Dosing Volume: Date: Certification 9: Draw Down: RiserSealed ❑ Yes (11 No RiserHeight: ❑ Yes ❑ No (Min.6in." nforced Tank: ❑ Yes ❑ No 1 Piece Tank. 0 Yes ❑ No No Check -valve ❑ Yes Pipe Size: inch diameter Pipe Length: feet *Schedule: Pressure Rated ❑ Yes ❑ No Approved fittings ❑ Yes ❑ No Certification #: *ENS: Date: Supply Line Installer Certification #: *EH S: Date: Pump Type: Installer. Dosing Volume: Certification 9: Draw Down: Inches *EHS: *Chain: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check -valve ❑ Yes ❑ No Approval St, PVC Unions ❑ Yes ❑ No yecDIS2pprOVeC pprq Vent Hole ❑ Yes ❑ No Anti -siphon Hole ❑ Yes ❑ No CDP File Number 194264 - 1 ciectrnc cuulomeni 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 ❑ N o Conduit Sealed ❑ Yes ❑ No THS: Pump Manually Operable ❑ Yes ❑ No *Activation Method: Date: Alarm Audible ❑ Yes ❑ No Approval Status ❑ Approved ❑ Disapproved Alarm Visible ❑ Yes ❑ No 2140 • Nations, Robert *Operation Permit completed byl Authorized State Agent: Owner/Applicant Signature: Date of Issue: 0 3/ 0 7/ 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 11 A. sewage septic system. Rule .1961 requires that a Type TYPE I1 A. septic system meet the following criteria: Minimum System Review ByThe Local Health Department: NIA Management Entity: OWNER Minimum System Inspection/Maintenance Frequency ByCertified 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 for a homelbusiness 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 tong 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 Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC Drawing Drawing Type: Operation Permit CDP File Number: 194264 -1 County File Number: 27028 Date: ! ! Olnch Scale: OBlock ON/A I IIIDLij I i I III EET I i ZI F-1� I I _71 1 I i I r--r � CONSTRUCTION For Office Use Only AUTHORIZATION *CDP File Number 194264-1 40 Scor' Davie County Health Department County ID Number: 210 Hospital Street Evaluated For: HDR/WWC •,� e,. P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax: 336-753-1680 0 6/ 1 6/ a 0 a 0 Applicant: Michael and Stacey Johnston Address: 222 Hidden Valley Lane City: Mocksville State/Zip: NC 27028 Phone #: (336) 492-6429 Address/Road M 222 Hidden Valley Lane Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 3 # of People: *Water Supply: EXISTING WELL Property Owner: Michael and Stacey Johnston Address: 222 Hidden Valley Lane City: Mocksville State/Zip: NC 27028 Phone #: (336) 492-6429 Subdivision: Hidden Valley Phase: Lot: 12 Directions Hwy 601 North Left on Allen Rd. right on Hidden Valley Classification: Provisionally suitable Minimum Trench Depth: a 4 Inches \Site Saprolite System? O Yes l8 No Minimum Soil Cover: 1 a Inches Design Flow: 4 8 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 x 7 5 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) n• S f T k *Proposed System: 25% REDUCTION Nitrification Field No. Drain Lines Total Trench Length Trench Spacing: Trench Width: Aggregate Depth: ep Ica 1 0 0 0 Gallons 1 -Piece: O Yes ®No Pump Required: OYes ®No O May Be Required 4 3 6 Sq. ft. Pump Tank: Gallons a 1-Piece:OYes ONo 1 0 9 ft GPM --vs— ft. TDH 9 O Inches O.C. ® Feet O.C. Dosing Volume: Gallons 3 OInches ® Feet Grease Trap: Gallons inches Pre -Treatment: O NSF OTS -1 OTS -11 / Septic Tank Installer Grade Level Required: 01011 O 111 01V Page 1 of 3 CDP File Number 194264 - 1 County ID Number: ' . red:®Yes ONO ONO, but has Available *Site Classification: Design Flow: A R 0 Soil Application Rate: 0 . 2 7 5 *System Classification/Description: TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System: 25% REDUCTION Nitrification Field 1 7 4 5 No. Drain Lines Total Trench Length: 5 436 Minimum Trench Depth: ft. Sq. ft. ❑ Open Pump System Sheet Trench Spacing: 9 O Inches O. (9 Feet O.C. Trench Width: — 3 R Inches Feet Aggregate Depth: inches Minimum Trench Depth: .1 4 Inches Minimum Soil Cover: 1 a Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: ) 4 Inches *Distribution Type: GRAVITY - PARALLEL (eq. d -box) Pump Required: OYes ®No O May Be Required Pre -Treatment: O NSF OTS -1 OTS -11 *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. Rhe 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. Rh,� g 2000 Th' Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit, not to xceed five years, and may be issued at the same time the Improvement Permit issued (NCGS 130A -336(b)). If the installation has not been -­w,tompleted 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: Authorized State 2140 - Nations, Robert Date of Issue: 0 6/ 1 7/ 2 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 Drawing Drawing Type: Construction Authorization CDP File Number: 194264 -1 County File Number: Date: 06/ 17 /.1015 O Inch Scale: O Block Q N/A Page 3of3 P1 P2 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 CDP File Number: 194264 - 1 County File Number: Date:.0.6./ 17 / .1 0 15 Click below to import an image from an external location: Drawing Type: Construction Authorization Page 3 of 3 P1 P2