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202 Westridge Road Lot 45OPERATION PERMIT Davie County Health Department ° ¢ 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Bobby Hall Address: 202 Westridge City: Advance State/Zip: NC 27006 Phone #: (336) 414-8888 Address/Road #: 202 Westridge Advance Structure: # of Bedrooms: # of People: *Water Supply: *CDP File Number 244513 - 1 5881031941 County ID Number: Evaluated For: REPAIR �ownship: /Property Owner: Bobby Hall Address: 202 Westridge City: Advance State/Zip: NC Phone #: (336) 414-8888 Property Location & Site I Subdivision: Westridge NC 27006 SINGLE FAMILY 3 2 PUBLIC *IP Issued by: *CA Issued by: 2140 - Nations, Robert Design Flow: 3 6 0 Soil Application Rate: 0 a 7 5 Nitrification Field No. Drain Lines Total Trench Length Trench Spacing: Trench Width: Aggregate Depth: M Phase: 2 Lot: 45 Hwy 158 east, right on Hwy 801, left on Hillcrest Dr. right on Westridge *System Classification/Description: TYPE III G. OTHER NON-CONV. TRENCH SYSTEMS Saprolite System? '.,Yes X, No *Distribution Type: GRAVITY -SERIAL Pump Required? 0 Yes X No, *Pre -Treatment: Drain field 1 3 0 9 Sq. ft. 1 3a8ft. 9 0Inches O.C. (9 Feet O.C. 3 Olnches (9 Feet inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover: a 4 Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: ) 4 Inches Page 1 of 4 *System Type: INFILTRATOR QUICK STANDARD Installer: Ronald Adams Certification #: 2577 *EHS: 2140 - Nations, Robert Date: 1 1/ 1 4/.1 0 1 7 Approval Status 0 Approved ❑ Disapproved CDP File Number 244513 - 1 County ID Number: 5881031941 Manufacturer: Pump Type: PT: se tic i anK inch diameter Manufacturer: Riser Sealed ❑ Yes Lat. ❑ Yes Reinforced Tank: ❑ Yes \ 1 Piece Tank: ❑ Yes Long: ❑ No STB: Approved fittings ❑ Yes ❑ No *EHS: Approval Status Gallons: *Chain: ❑ Approved ❑ Disapproved Installer: Date: Certification #: Date: *EHS: Valves Accessible *Filter Brand: Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No ST Marker: ❑ Yes ❑ NO Date: ❑ Reinforced Tank: ❑ Yes ❑ NO PVC unions Approval Status Yes ❑ No ❑ El Approved El Disapproved 1 Piece Tank: El Yes El NO NO Manufacturer: Pump Type: PT: Gallons: inch diameter Date: Riser Sealed ❑ Yes Riser Height: ❑ Yes Reinforced Tank: ❑ Yes \ 1 Piece Tank: ❑ Yes ❑ No ❑ No (Min. 6 in.) ❑ No ❑ No Pump Tank Installer: Certification #: *EHS: Date: Approval Status ❑ Approved ❑ Disapproved / Pump Type: Supply Line Pipe Size: inch diameter Installer: Pipe Length: feet Certification #: *Schedule: *EHS: Pressure Rated ❑ Yes ❑ No Date: Approved fittings ❑ Yes ❑ No *EHS: Approval Status *Chain: ❑ Approved ❑ Disapproved / Pump Type: Installer: Dosing 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 Page 2 of 4 CDP File Number 244513 - 1 County ID Number: 5881031941 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: Approval Status Alarm Audible El Yes ElNo ❑Approved ❑ Disapproved Alarm Visible El Yes ElNO 2140 - Nations, Robert *Operation Permit completed by: Authorized State Agenic �—� Date of Issue: 1 1/ 1 9/.1 0 1 7 Owner/Applicant Signature: This system has been installed in compliance with applicable NC General Statutes: Article 11, Chapter 130A, Rules for Sewage Treatment and Disposal, 15A NCAC 18A.1900 et. Seq., and all conditions of the Improvement Permit and Construction Authorization. This property is served by a TYPE iii G. sewage septic system. Rule .1961 requires that a Type TYPE iii G. septic system meet the following criteria: Minimum System Review By The Local Health Department: N/A Management Entity: OWNER Minimum System Inspection/Maintenance Frequency By Certified Operator: N/A Reporting Frequency By Certified Operator: N/A Rule .1961 requires that a Type IV and V septic systems designed for a home/business owner must maintain a valid contract with a public management entity with a certified operator or a private certified operator for the life of the septic system. Rule .1961 requires that Type VI septic systems designed for a home/business owner must maintain a valid contract with a public management entity with a certified operator for the life of the septic system. Rule. 1961 (2) (e) requires a contract shall be executed between the system owner and a management entity prior to the issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the system owner and certified operator are the same. The contract shall require specific requirements for maintenance and operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long as the system is in use, and other requirements for the continued proper performance of the system. It shall also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. 9 Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 3of4 OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC Drawing Drawing Type: Operation Permit CDP File Number: 244513 - 1 County File Number: 5881031941 27028 Date: / / O Inch Scale: O Block O N/A Page 4 of 4 P1 P2 P3 OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC CDP File Number: 27028 County File Number: Date:. . / Click below to import an image from an external location: Drawing Type: Operation Permit 5881031941 Page 4 of 4 P1 P2 P3 Drain Field: System Final Inspection Log: Characters Remaining 4000 Septic Tank: Pump Tank: Supply Line: Pump Requirements: Electrical Equipment: P1 P2 P3 Characters Remaining 4000 Characters Remaining 4000 Characters Remaining 4000 Characters Remaining 4000 Characters Remaining 4000 (BolaY f/a DAVIE .COUNTY HEALTH DEPARTMENT ptic Tank) Improvements Permit and Certificate of Completion Ito Xbsorption Sewage Disposal System - G.S. Chapter 130 -Article 13C) OWNER OR'CONTRACTOR _t DATEar,:7;� PERMIT LOCATION [rIAGIerPASSc ♦,� 130 S.R. N0. SUBDIVISION NAME"..; LOT.N0. "' SECTION OR BLOCK NO. N0, BEDROOMS" NO. BATHROOMS; d� _ GARBAGE DISPOSAL UNIT YES 12o NO ❑ .'-AUTO. DISHWASHER YES' Q- ,No ❑ AUTO.. WASH. MACHINE YES W- .NO ❑ ; . SITE SUITABLE YES rh N0 ❑ SIZE OF TANK I J.db gal. •,` NITRIFICATION FIELD sq. ft. DEPTH OF STONE IN LINES: 1� ew WATER SUPPLY: Individual Public .❑ IMPROVEMENTS PERMIT BY House Trailer 800 Gal. 400 Sq. Ft. Two Bedroom House 800 Gal: 600 Sq. Ft. .Three Bedroom House 900 Gal. 900,5q. Ft. Four.Bedroom.House 1000 Gal. 1200 Sq. Ft. /goo r' e S Gu/ S dh crr'crcit i 6 INSTALLED BY . s ' DAVIE COUNTY HEALTH DEPARTMENT (Septic Tank) Improvements Permit and Certificate of Completion (Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C) OWNER OR CONTRACTOR CJB R 2u, IcI- DATE / ,Rb 7 7 PERMIT 1 LOCATION U er-P I -SS PJ. N9 13 0 S.R. NO. SUBDIVISION NAME WeeTk4jA e. LOT NO. 4-r SECTION OR BLOCK NO. HOUSE 0 MOBILE HOME ❑ BUSINESS ❑ NO. BEDROOMS 3 NO. BATHROOMS a//2- GARBAGE DISPOSAL UNIT YES I- NO ❑ AUTO. DISHWASHER YES NO ❑ AUTO. WASH. MACHINE YES Cts NO ❑ SITE SUITABLE YES C NO ❑ SIZE OF TANK /aZO- gal. NITRIFICATION FIELD 1,,,L5-Dsq. ft. DEPTH OF STONE IN LINES: o�� !ectal WATER SUPPLY: Individual Public ❑ IMPROVEMENTS PERMIT BY House Trailer / 800 Gal. 400 Sq. Ft. Two Bedroom House 800 Gal. 600 Sq. Ft. Three Bedroom House 900 Gal. 900 Sq. Ft. Four Bedroom House 1000 Gal. 1200 Sq. Ft. ;to 0 tjQl, f4AX a 1% n e s'? �3c oh Ca>1c/'e� s/a6 'yS�X3X o? ��Qack /,eueL , INSTALLED BY CERTIFICATE OF COMPLETION By Date 3 (8/16/73) *Construction must comply with all other applicable State and local regulations LOT AREA (ra Ke S�r-� we -ll W r 11 ; n Fr 12 P G .�A