2076 Hwy 601S (2)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: Fred O Ellis
Address: 6943 NC Hwy 801 S
City: Mocksville
State/Zip: NC 27028
Phone #: (336) 909-0717
Property Loca
Address/Road #: Subdivision:
2076 Us Hwy 601 S
Mocksville NC 27028
Structure: RESTAURANT
# of Bedrooms:
# 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
*CDP File Number 198050 - 2
County ID Number:
Evaluated For: REPAIR
�ownship:
//Property Owner: Fred O Ellis
Address: 6943 NC Hwy 801 S
City: Mocksville
State/Zip: NC 27028
hone #: (336) 909-0717
ion & Site Information
Phase:
Directions
601 South
Lot:
*System Classification/Description:
TYPE III G. OTHER NON-CONV. TRENCH SYSTEMS
Saprolite System? J Yes X, No
*Distribution Type: PUMP TO GRAVITY Pump Required?
X Yes 0 No,
*Pre -Treatment:
Drain field
Nitrification Field a 1 8 a Sq. ft.
No. Drain Lines 7
Total Trench Length: 7 a 7 ft.
Trench Spacing: 9 0Inches O.C.
(9 Feet O.C.
Trench Width:3 OInches
(9 Feet
Aggregate Depth: 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: Randy Miller
Certification #: 1128
*EHS: 2140 - Nations, Robert
Date: 0 a/ a 3/ a 0 1 7
Approval Status
X❑ Approved ❑ Disapproved
CDP File Number 198050 - 2
County ID Number:
Manufacturer:
Shoaf
se tic i anK
PT:
Manufacturer:
a
inch diameter
Lat.
Gallons:
1500
4 (
5 feet
Long:
Date:
STB:
1/
1 8
/ x 0 1 7
Riser Sealed
Gallons:
Yes
❑
Installer:
Riser Height:
Date:
/
/
Certification #:
Reinforced Tank:
d
Yes
❑
*EHS:
\ 1 Piece Tank:
*Filter Brand:
N/A
❑
NO
Approved ❑ Disapproved
Flow Adjustment Valve
X
Yes
❑
No
ST Marker:
❑ Yes
❑ NO
Date:
Yes
Reinforced Tank:
❑ Yes
❑ NO
Approval Status
Approval Status
X
Yes
❑
El
Approved El Disapproved
1 Piece Tank:
El Yes
El NO
Yes
❑
Manufacturer:
Shoaf
Supply Line
PT:
353
a
inch diameter
Installer:
Gallons:
1500
4 (
5 feet
Certification #:
Date:
0
1/
1 8
/ x 0 1 7
Riser Sealed
0
Yes
❑
No
Riser Height:
Pressure Rated
Yes
❑
NO (Min. 6 in.)
Reinforced Tank:
d
Yes
❑
NO
\ 1 Piece Tank:
0
Yes
❑
NO
Pump Tank
Installer: Randy Miller
Certification #: 1128
*EHS: 2140 - Nations, Robert
Date: 0 a/ a a/ a 0 1 7
Approval Status
0 Approved ❑ Disapproved
/ Pump Type: zoeler
Supply Line
Installer:
Pipe Size:
a
inch diameter
Installer:
Randy Miller
Pipe Length:
4 (
5 feet
Certification #:
1128
Inches
*EHS:
2140 - Nations, Robert
*Schedule:
40
Pressure Rated
X❑ Yes
❑ No
Date:
0 a/ a 3/ a 0 1 7
Approved fittings
X❑ Yes
❑ NO
Valves Accessible
Approval Status
Yes
❑
No
❑X
Approved ❑ Disapproved
Flow Adjustment Valve
X
Yes
❑
No
/ Pump Type: zoeler
Installer:
Rusty Miller
Dosing Volume:
-
Gal Certification #:
1129
Draw Down:
Inches
*EHS:
2140 - Nations, Robert
*Chain: ROPE
0 a/ a a/ a 0 1 7
Date:
Valves Accessible
❑X
Yes
❑
No
Flow Adjustment Valve
X
Yes
❑
No
Check -valve
❑X
Yes
❑
NO
Approval Status
PVC unions
X
Yes
❑
No
X
Approved ❑ Disapproved
Vent Hole
❑X
Yes
❑
NO
Anti -siphon Hole
❑X
Yes
❑
No
Page 2 of 4
CDP File Number 198050 - 2
County ID Number:
NEMA 4X Box or Equivalent
❑X
Yes
❑
NO
Installer:
Rusty Miller
Box 12 inches Above Grade
❑X
Yes
❑
NO
1129
Certification #:
Box Adj. To Pump Tank
X
Yes
❑
No
Conduit Sealed
❑X
Yes
❑
NO
*EHS:
2140 - Nations, Robert
Pump Manually Operable
X
Yes
❑
No
*Activation
Date:
0 a/ a 3/ x 0 1 7
Method:
PIGGYBACK
Alarm Audible ® Yes
Alarm Visible 0 Yes
2140
*Operation Permit completed by_
Authorized State
Owner/Applicant Signature:
Approval Status
El No
El No 0 Approved ❑ Disapproved
ns, Robert
Date of Issue: 0 a/ a 3/ a 0 1 7
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
tJ
CDP File Number: 198050 - 2
County File Number:
27028 '?S`� Date:
O Inch
Scale: 1 , 0 , 0 , (9 Block
i 0 N/A
s.
4 a J V .0
Page 4of4
<�_ �-. I ,
P1 P2 P3
F
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
Page 4 of 4 P1 P2 P3
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Septic Tank:
Pump Tank:
Supply Line:
Pump Requirements:
Electrical Equipment:
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