193 Graywood Court Lot 16I
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: The Pool Store, LLC
Address: 914 Yadkinville Rd
City: Mocksville
StatefZip: NC 27028
Phone #: (336) 941-0155
ro
Address/Road #:
193 Graywood Court
Advance NC 27006
Structure: SINGLE FAMILY
# of Bedrooms: 4
# of People:
*Water Supply: WA
*CDP File Number 137239-1
E7-140-AO.016
County ID Number:
Evaluated For, HDR/WWC
Township:
%property owner: Todd and Melanie Major
Address: 193 Graywood Ct
City: Advance
State/Zip: NC 27006
Phone #:
ierty Location & Site Information
Subdivision: Reland Place Phase: Lot: 16
Directions
hwy .158 Left on Redland Rd. Left into Redmeadow
Drive Right on Graywood to end.
*IP Issued by. 'System Classification/Description:
TYPE 11 A CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
'CA issued by: 2140 -Nations, Robert SaproliteSystem? OYes QNo
Design Flow: 3 6 0GRAVITY-SERIAL Pump Required?
Distribution Type: O Yes (DNo
Soil Application Rate: 0 , a 7 5 *Pre Treatment:
Drain field
Nitrification Field
No. Drain Lines
Total Trench Length
Trench Spacing:
Trench Width:
Aggregate Depth:
Sq. ft.
a a 0.
9 Inches O.C.
Feet O.C.
3 Oinches
o Feet
inches
Minimum Trench Depth: 3 6
Minimum Soil Cover, a 4
Maximum Trench Depth: 3 6
Maximum Soil Cover: a 4
Inches
*System Type: INFILTRATOR QUICK 4 STANDARD
Installer: Randy Miller
Certification #: 1128
'EH S: 2140 - Nations, Robert
Date: 0 5/ 1 9/.2 0 1 4
Inches 'Approval Status
Inches ®; Approved O Disapproved
Inches /
CDP File Number 137239 - 1
Manufacturer.
STB:
Gallons:
Date:
'Filter Brand:
ST Marker. ❑ Yes ❑ No
nforced Tank: ❑ Yes ❑ No
1 Piece Tank: ❑ Yes ❑ No
w
Manufacturer.
PT:
Gallons:
Date:
/
/
RiserSealed ❑
Yes
❑
No
RiserHeight: ❑
Yes
❑
No (Min.6 in.)
einforced Tank: ❑
Yes
❑
No
1 Piece Tank: ❑
Yes
❑
No
/ Pipe Size: inch diameter
Pipe Length: feet
"Schedule:
Pressure Rated ❑ Yes ❑ No
Approved fittings ❑ Yes ❑ No
County ID Number: E7 -140-A0-016 A
C TanK
Lat. -
Long:
Installer:
Certification 4:
"EHS:
Date: / I
Approval`status
❑Approved El Disapprov ed
Pump Tank
Installer:
Certification #:
*EH S:
Date:
Date: I I
Approval Status
❑ 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 Hale
❑ Yes
❑
No
Anti -siphon Hole
❑ Yes
❑
No
CDP File Number 137239-1
NEMA 4X Box or Equivalent
Box 12 inches Above Grade
Box Adj. To Pump Tank
Conduit Sealed
Pump Manually Operable
*Activation Method:
County ID Number: E7-140•AO-016
Approval Status
Ala rm Audible ❑ Yes ❑ N o
D Approved ❑ Disapproved
Alarm Visible ❑ Yes ❑ No
2140 - Nations, Robert
*Operation Permit completed by:
Authorized State Agent: Date of Issue: 0 5/ 1 9/ 2 0 1 4
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 II A. sewage septic system.
Rule .1961 requires that a Type TYPE 11 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 fora home/business owner must maintain a valid contract with a
public management entitywith a certified operator forthe life of the septic system.
Rule. 1961 (2) (e) requires a contract shall be executed between the system owner and a management entity prior to the
issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the
system owner and certified operator are the same. The contract shall require specific requirements for maintenance and
operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long as the
system is in use, and other requirements for the continued proper performance of the system. It shall also be a condition of
the Operation Permit that subsequent owners of the systems execute such a contract.
OHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Electric Equipment
❑
Yes
❑
No
Installer:
❑
Yes
❑
No
Certification:
❑
Yes
❑
N o
❑
Yes
❑
No
*EH S:
❑
Yes
❑
No
Date:
Approval Status
Ala rm Audible ❑ Yes ❑ N o
D Approved ❑ Disapproved
Alarm Visible ❑ Yes ❑ No
2140 - Nations, Robert
*Operation Permit completed by:
Authorized State Agent: Date of Issue: 0 5/ 1 9/ 2 0 1 4
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 II A. sewage septic system.
Rule .1961 requires that a Type TYPE 11 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 fora home/business owner must maintain a valid contract with a
public management entitywith a certified operator forthe life of the septic system.
Rule. 1961 (2) (e) requires a contract shall be executed between the system owner and a management entity prior to the
issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the
system owner and certified operator are the same. The contract shall require specific requirements for maintenance and
operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long as the
system is in use, and other requirements for the continued proper performance of the system. It shall also be a condition of
the Operation Permit that subsequent owners of the systems execute such a contract.
OHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT
Davie County Health Department CD File Number: 1372 -1
210 Hospital Street
P.O. Box 848
County ile Number: E�-1ao-Ao-o1s
Mocksville NC 27028 ate: J /
C c. l -� S Gt C'' (j Q Inch
S e: QBlock
DrawingDrawing Type: Operation Perml �� �u rj IN �� 0N/p
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HEALTH DEPARTMENT RELEASE
Davie County Health Department
-- Environmental Health Section
210 Hospital Street
Mocksville, NC 27028
Phone:336-753-6780 Fax:336-753-1680
Permit Valid Until: 04/22/2019
Applicant: The Pool Store, LLC Property Owner: Todd and Melanie Major
Address: 914 Yadkinville Rd Address: 193 Graywood Ct
City: Mocksville City: Advance
State/Zip: NC / 27028 State/Zip: NC / 27006
Phone #: (336) 941-0155 Phone #:
Property Location & Site Information
Address: 193 Graywood Court Subdivision: Reland Place Phase: Lot: 16
Road#: Advance NC 27006 Township:
*Structure: SINGLE FAMILY
# of Bedrooms: 4 # of People: Directions:hwy 158 Left on Redland Rd. Left into
Redmeadow Drive Right on Graywood to end.
*Water Supply: N/A Type of business:
Basement: D Yes ED No Total sq. Footage: No. Of Employees:
*Proposed Improvement: Pool 16x32
*Release Conditions:
**Site Plan/Drawing attached.** Total Time: (HH:tM4)
OHand Drawing OImport Drawing Hours Minutes
Activity Code:
HEALTH DEPARTMENT RELEASE
iffNO ` Davie County Health Department
-I Environmental Health Section
210 Hospital Street
Mocksville, NC 27028
Phone:336-753-6780 Fax:336-753-1680
Permit Valid Until: 04/22/2019
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? F-1 Yes FlNo
Applicant/Legal Reps. Signature:
*Issued By: Nations, Robert
Authorized State Agent:
*Date:
*Date of Issue: 04/22/2014
**Site Plan/Drawing attached.** Total Time: (HH:MM)
OHand Drawing ()Import Drawing Hours Minutes
Activity Code: