722 Baileys Chapel Rd OPERATION PERMIT or nice se n v
Davie County Health Department *CDP File Number 157292-1
210 Hospital Street 1-18-000-00-050
P.O.Box 848 County ID Number.
Mocksville NC 27028 Evaluated For. REPAIR
Phone: 336-753-6780 Fax:336-753-1680 Township:
Applicant: P. Keith Spry Property owner. P. Keith Spry
Address: 722 Baileys Chapel Road Address: 722 Baileys Chapel Road
City: Advance City: Advance
State2ip: NC 27006 State/Zip: NC 27006
Phone#: Phone#:
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
722 Baileys Chapel Rd
Advance NC 27006 Directions
Structure: SINGLE FAMILY Hwy;64 East , left on Hwy 801. 3 miles to Baileys
Chapel Rd on Right. Second house on left past
#of Bedrooms: 2 church.
#of People:
*Water Supply: NIA
*IP ssI
*System Classification/Desedption:
ued by.
TYPE 11 A CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by: 2140-Nations,Robed
Saprolite System? QYes QNo
Design Flow: a 4 0 *Distribution Type: GRAvITY-PARALLEL(eq.d-box) Pump Required?
QYes ONo
Sol Application Rate: 0 3 *Pre Treatment:
Drain field
Nitrification Field 8 0 0 Sq.ft. *System Type: INFILTRATOR QUICK STANDARD
Na. Drain Lines 2 Installer: Jamie Barnes
Total Trench Length: 2 0 0 ft• Certification#: 1018
Trench Spacing: _ 9 Inches O.C.
(*)Feet O.C. 'EH S: 2140-Nations,Robert
Trench Width: _ 3 Qlnches
Q# Feet Date: 0 9 / 0 5 / 2 0 1 4
Aggregate Depth: inches
Minimum Trench Depth: 3 6
Inches
777
Minimum Soil Cover -
a 4 Inches ApprovalStatus
Maximum Trench Depth: 3 6 Inches
® Approved Qisapproved
Maximum Soil Cover. a 4
Inches
CDP File Number 157292 - 1 Septic Tank County ID Number: H8-000-00.050
'
Manufacturer. Lat.
Long:
STB: .
Gallons: Installer
Date: Certification#:
*EH S:
*Filter Brand:
ST Marker: ❑ Yes ❑ No Date:
Reinforced Tank: El Yes ❑ No Approval Status
1 Piece Tank: El Yes El No =❑ Approved❑'Disapproved
Pump Tank
Manufacturer. Installer.
- PT: Certification#:
Gallons: *ENS:
Date: Date:
RiserSealed ❑ Yes ❑ No
Riser Height: ❑ Yes . ❑ No (Min.6 in.)
Approval Status
Reinforced Tank: ❑ Yes ❑ No
O Approved❑ Disap@roved
1 Piece Tank:..❑ YeS ❑ No
Supply line
7eLe
ize: inch diameter installer.
gth: feet CertificationSchedule:
*EH S:
Pressure Rated ❑ Yes ❑ No Date: 1
Approved fittings ❑ Yes ❑ NO ,Approval Status
❑ Approved❑ Disapproved
Pump e
Pump Type: Installer:
Dosing Volume: — Gal Certification#:
Draw Down: Inches *EHS.
*Chain:
Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ N o
Check-valve p Yes ❑ No Approval Status
' -
PVC unions El Yes O No ❑ Approved O Dlsapprovetl
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole ❑ Yes ❑ No
CDP File Number 157292 - 1 County ID Number: "s-a00-o0•oso
Electric Equipment
NEMA4XBoxorEquivalent ❑ 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 ❑ Yes C3No
❑ Approved 11] Disapproved
Alarm Visible ❑ Yes ❑ No
2140-Nation,Robert
*Operation Permit completed by:
Authorized State Agent: Date of Issue: 0 9 / 0 5 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 11 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.
WA
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 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 ownerand certified operator are the same. The contract shall require specific requirements formaintenance 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.
eHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT 157292 - 1
Davie County Health Department CDP File Number:
210 Hospital Street HMO-00-050
P.O.Box 84$ County File Number:
Mocksville NC 27028 Date:
Olnch
Scale: O
Drawing Drawing Type: Operation Permit OBlock
= ft.
O
i I fI
I
CONSTRUCTION For office use Only
AUTHORIZATION "CDP File Number:.,157292-`1
Davie County Health Department County ID Number H8-Uo0-oo-050.
210 Hospital Street Evaluated For REPAIR
., ,. P.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone: 336-753-6780 Fax: 336-753-1680 0 8 / 1 9 / 2 0 1 9
Applicant: P. Keith Spry Property Owner. P. Keith Spry
Address: 722 Baileys Chapel Road Address: 722 Baileys Chapel Road
City: Advance City: Advance
State2ip: NC 27006 State0p: NC 27006
Phone#: 1, Phone#:
Property Location & Site information
Address/Road#: Subdivision: Phase: Lot:
722 Baileys Chapel Rd
Advance NC 27006 Directions
Structure: SINGLE FAMILY Hwy 64 East , left on Hwy 801. 3 miles to Baileys Chapel
Rd on Right. Second house on left past church.
#of Bedrooms: 2
#of People:
'Water Supply: N/A
System Specifications
Minimum Trench Depth: a 4
Site Classification: Provisionally Suitable Inches
Minimum Soil Cover. 1
Saprolite System? OYes &No Inches
Design Flow: a 4 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 3 Maximum Soil Cover: 2 4 Inches
'System Classification/Description: =Distribution Type: GRAVITY-PARALLEL(eq.d-box)
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic lank:
Gallons
"Proposed System: 25%REDUCTION 1-Piece: Oyes ONO
Pump Required: OYes ONo OMay Be Required
N ftrification Field 8 0 0
Sq. ft. Pump Tank: Gallons
No. Drain Lines a 1-Piece: OYes ONo
Total Trench Length: a @ $ GPM—vs— ft. TDH
Trench Spacing: OFeet
nches O.C.
= 9 . O.C. Dosing Volume: _ Gallons
Trench Width: 3 gInches
Feet Grease Trap: Gallons-
Aggregate Depth: inches
Pre-Treatment: ONSF OTS-I OTS-II
Septic Tank Installer Grade Level Required: 01011 0111 OIV
CDP File Number 157292 - 1 County ID Number: HB-000-00-050
[] Open Pump System Sheet
Repair System Required:OYes ONO ONo,but has Available Space
rDesign
System Trench Spacing: Inches O.C.
ification: — S Feet O.C.
Trench Width: Inches
w: _ Fest
Aggregate Depth:
Soil Application Rate: inches
'System Classification/Description: Minimum Trench Depth: Inches
Minimum Soil Cover.
Inches
Maximum Trench Depth:
"Proposed System: Inches
Maximum Soil Cover:
Nitrification Field Inches
Sq. ft.
No. Drain Lines 'Distribution Type:
Total Trench Length: ft Pump Required: OYes ONo 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. c.
7!
"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.
2(
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 sametime the Improvement Permit issued(NCGS 130A-336(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 besuspended or revoked(.1937(g)).The person owning or controlling the system shall be responsible forassuring compliance
with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance,monitoring,reporting and repair.
Applicant/Legal Reps. Signature Required? OYes ONO
Applicant/Legal Reps. Signature: Date:
"Issued By: 2140-Nations,Robert Date of Issue: . 0 8 1 9. I a 0 1 4
Authorized State Agent: Malfunction Log Oyes
*Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Paae 2 of 3
CONSTRUCTION AUTHORIZATION 157292 1
Davie County Health Department CDP File Number:
210 Hospital Street
1-18-000-00-050
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 08 / 1' 9 / .1 0 1 4
Olnch
Drawing Drawing Type:.Construction Authorization Scale: . OON/A k ft.
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