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1316 Bear Creek Church Rd -- ' or Tfice use Only OPERATION PERMIT Davie County Health Department *CDP File Number, 199260-1 210 Hospital Street iot-000-00•042 P.O.Box 848 County ID Number., Mocksville NC 27028 Evaluated For."REPAIR' Phone:336-753.6780 Fax:336-753-1680 Township: FApplicant: Christopher Tomel Property owner. Christopher Tomel Address: 1316 Bear Creek Church Rd Address: 1316 Bear Creek Church Rd City: Mocksville City: Mocksville State/Zip: NC 27028 State0p: NC 27028 Phone#: (336)9714889 Phone#: (336)971-4889 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: 1316 Bear Creek Church Road Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 601 North left on Liberty Church Rd. left on Beat Creek church Rd. house on right #of Bedrooms: 3 #of People: *Water Supply: EXISTING WELL *IP I 'System Class ification/Descdption: ssued by. 21ao-Nations,Robert TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140-Nations,Robert Seprolite System? OYes ialslo Design Flow: 3 6 0Distribution Type: GRAVITY-SERIAL Pump Required? OYes QNo Soil Application Rate: 0 a 3 5 *Pre Treatment: Drain field rcation Field 1 3 0 9 Sq.ft. *System Type: INFILTRATOR QUICK 4 STANDARD rain Lines 3 Installer: William Blakely Total Trench Length: 3 2 7 8• Certification#: 1886 Trench Spacing: 9 Inches O.C. (DFeet O.C. *EH S: 2140-Nations.Robert Trench Width: — 3 Oinches ffeet Date: 0 3 / 0 8 / 2 0 1 6 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. 4 Inches ApprovalStatus� . Mmum Trench Depth: 3 6 Inches ® Approved O Disapproved Maxiaximum Soil Cover. a 4 Inches CDP File Number 199260 - 1 Septic Tank County ID NumbeE: D1�DI-000-00-042 Manufacturer. Lat. Long: STB: Gallons: Installer. Date: / / Certification#: *EHS: *Filter Brand: ST Marker. ❑ Yes ❑ No Date: Reinforced Tank: E] Yes ElNo Approval Status Piece Tank: ❑ Yes ❑ No ❑ Approved❑ ,Dlsapproved„ �� Pump Tank Manufacturer. installer PT: Certification#: Gallons: *EHS: Date: / / Date: RiserSealed ❑ Yes ❑ NO RiserHebht: ❑ Yes ❑ No (Minae in.) Approval Stgtusl einforced Tank: ❑ Yes ❑ No SCI Approved❑ Disappr wed, 1 Piece Tank: ❑ Yes ❑ No Supply Line Pipe Size: inch diameter Installer. Pie Length: feet Certification#: *Schedule: *EHS. Pressure Rated ❑ Yes ❑ No Date: Approved fittings ❑ Yes ❑ No640 Approval Status ,y, ❑ Approve do 'Disapproved -a I {!/ 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 Statusk PVC unions ❑ Yes El No ❑ Approved L7 Disapproved ❑ Yes ❑ No Vent Hole Anti-siphon Hole ❑ Yes ❑ No CpP.File-Number. 199260 - 1 County ID Number: DI.000.00.042 Electric Equipment NEMA4XBoxorEquivalent ❑ Yes ❑ No Installer. Box 12 inches Above Grade ❑ Yes ❑ No Certification#: Box Adj. Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No 'ENS: Pump Manually Operable ❑ Yes ❑ No 1 'Activation Method: Date: y Alarm Audible El Yes ❑ No ApprovalStus , - ❑ Approved❑ Disapproved Alarm visible ❑ Yes ❑ No 2140-Nations,Robert "Operation Permit completed by: Authorized State Agent Q Date of Issue: 0 3 0 8 2 0 1 6 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 u a sewage septic system. Rule.1961 requires that a Type TYPE 11 A. septic system meet the following criteria: Minimum System Review By The Local Health Department: NIA Management Entity: OWNER Minimum System InspectioniMaintenance Frequency By Certified Operator: N/A Reporting Frequency By Certified Operator.WA 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 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 priorto the issuance of an Operation Permitfor a system required to be maintained bya public or private management entity,unless the system owner and certified operator are the same. The contract shall require specific requirements formaintenance and operation, responsibilities of the ownerand 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. @Hand Drawing Dlmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT 199260 —1 Davie County Health Department CDP File Number: 210 Hospital Street Di-000.00-042 P.O.Box 848 County File Number: Mocksville NC 27028 Date: / / Olnch Drawing Drawing Type: Operation Permit Scale: , ON A k f 1............. I t- I i j I Date Attendees Topic Meetin Objectives Notes Q Q d fl l x I#/ , Action Items • _ - For Office Use Only CONSTRUCTION AUTHORIZATION "CDP File Number 19.9260-1,Davie County Health Department County ID Number: D1-ooaoo-oat 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 a / 0 9 / 2 0 a 1 Applicant: Christopher Tomel Property Owner: Christopher Tomel Address: 1316 Bear Creek Church Rd Address: 1316 Bear Creek Church Rd City: Mocksville City: Mocksville State/Zip: NC 27028 StatefZip: NC 27028 Phone#: (336)971-4889 Phone#: (336)971-4889 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: 1316 Bear Creek Church Road Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 601 North left on Liberty Church Rd. left on Bear Creek church Rd. house on right #of Bedrooms: 3 #of People: `Water Supply: EXISTING WELL System Specifications Minimum Trench Depth: 2 4 Site Classification: Provisionally Suitable Inches Minimum Soil Cover. 1 a Saprolite System? ()Yes ®No Inches Design Flow: 3 6 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-SERIAL TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: Gallons 'Proposed System: 25%REDUCTION 1-Piece: OYes 0 N Pump Required: OYes ONo OMay Be Required Nitrification Field 1 3 0 9 Sq.ft. Pump Tank: Gallons No.Drain Lines 3 1-Piece:OYes ONo Total Trench Length: 3 a 7 ft GPM vs— ft. TDH Trench Spacing: _ 9 @Feet Inches O.C. Dosing Volume: Gallons O.C. Trench Width: 3 2Inches - `= Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS-1 O:TS-11 Septic Tank Installer Grade Level Required: 01 011 0111 OIV Donn 4 of Z COP File Number 199260 - 1 County ID Number. U1-000-00-042 ' ❑ Open Pump System Sheet Repair System Required:OYes ONO @No, but has Available Space rDesign System Trench Spacing: O Inches 0. . ification: — O Feet O.C. Trench Width; Inches w: — (0 Feet SoilApplication Rate: Aggregate Depth: inches Minimum Trench Depth: *System Classification/Description: Inches Minimum Soil Cover. Inches Maximum Trench Depth: *Proposed System: Inches Maximum Soil Cover: Nitrification Field Sq. Inches ft. No. Drain Lines *Distribution Type: Total Trench Length: ft. Pump Required: OYes ONo OMay Be Required Pre Treatment: ONSF OTS-1 OTS-11 "e) *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 wayguarentees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. This Authorization for Wastewater System Construction shalt be valid fora person equal to the period of validity of the improvement Permit,not to exceed five years,and may be issued atthe same time the improvement Permit issued(NCGS 130A-336(b)) If theinstallation has not been completed during the period of validity of the Construction Permit:the information submitted In the application for a permit orConstruction Authorization is found to have beet incorrect,falsified or changed,or the site Is altered,the permit orConstruction 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: 1 Issued By: 2140-Nations,RobertDateof Issue: 0 2 / 0 9 / 2 0 1 6 Authorized State Age Malfunction Log OYes @Hand Drawing Oimport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION 199260 - 1 Davie County Health Department CDP File Number: - - 210 Hospital Street D1-000-00-042 P.O.sox 848 County File Number: Mocksville NC 27028 Date: 0 .1 / 0 9 / 2 0 1 6 Q Inch Drawing Drawing Type: Construction Authorization Scale: . 08Ak `ft. f r i CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: 199260- 1 P.O.Box 848 DI.000.00-042 Mocksville NC 27028 County File Number: Date: .O .a l 09 / .1016 Click below to Import an Image from an external location: Drawing Type:Construction Authorization APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT&ATC Davie County-Environmental Health P.O.Boz 848/210 Hospital Street ` Mocksville,NC 27028 ^at (336)753-6780/Fax(336)753-1680 N Application For. ❑Site Evaluation/Improvement Permit ❑Authorization To Construct(ATC) go13oth Type of Application: ❑New System repair to Existing System ❑Expansion/Modification of Existing System or Facility •"IMPORTAN7*"THIS APPLICATION CAWOT BE PROCESSED UNLESS ALL OF THE REQUIRED !� INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. (, APPLICANT INFORMATION V Name to be Billed Contact Person Balling Address,/.& Home Phone i!3)kI 42 1Jei_ City/StatelL 1112&1,1& l?ajss Business Phone Name on Permit/ATC if D fferent than Above Mailing Address Ci /Statemp PROPERTY INFORMATION *Date House/Facility Comers Flagged NOTE: A survey plat or site plan must accompany this application. Included:❑Site Plan ❑Plat(to scale) (Perot is valid for 60 months with site plan,no expiration with complete plat) , Owner's Name �— Phone Number =f/Ql_•l�pG Owner's Address City/State/Zip.e%ftA0A7JW.A47 Z72a-pis PropertyAddrm=,dr ! t City/a,A%gr Lot Size-4,&,r,-Tax PIN# Subdivision Name(if applicable) wari Section/Lot# Directions To Site: _ If the answer to arty of the following questions is"yes",supporting documentation must be attached, v s �� Are there any existing wastewater systems on the site? Gffes❑No Does the site contain jurisdictional wetlands? ❑Yes BNo Are there any easements or right-of-ways on the site? ❑Yes ONO ��, Is the site subject to approval by another public agency? C1 yes ef4o D f-�-oq-6 Will wastewater other than domestic sewage be generated? ❑Yes M o IF RESIDENCE FILL OUT THE BOX BELOW #People !. #Bedrooms _3_ #Bathrooms _ Garden Tub/Whirlpool gy6s ❑No Basement est❑No Basement Plumbing: ❑Yes Rlffo IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility,water consumption) FOODSERVICE ONLY: #Seats Type system requested: Peonventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type:❑County/City Water ❑New Well [H!5sting Well ❑Community Well Do you anticipate addition or e�pans�ons of thefaciliy this system is intended to serve?B'Xes ❑No If yes,what type? X r, 0-00.v-% .'r► UrAse � This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,tl:e intended use changes,or if the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corers and 10 fl ' g or staking the house/facility location,proposed well location and the location of any other amenities. Site Revisit Charge Property owner's or owner's legal representative signature Date(s): 1.>%� Client Notification Date: Dat EHS: Sign given ❑Yes❑No Account# � ~� Revised 11/06 Invoice# Davie County Health Department Environmental Health Section P.O.Box 848 z ' 210 Hospital Street : `f f C' Courier#:0940-06 Mocksville,NC 27028 , .rrr Phone:(336)-753-6780 Fax:(336)-753-1680 Information Needed to Request a copy of a Septic System Record The following form must be completed fully whenever requesting a septic layout for your property or property that you are considering for. •Septic System Maintenance such as pumping,jetting,terral'ift,distribution, etc. • Real Estate Listing or Transaction • Home Replacement •Additions or replacement of a pool,deck,room(s)onto an existing home,outbuilding or garage whether attached or not. •Appraisal •A recent purchase • Landscaping or grading •General information and possible future use/need You can return the completed form to the Davie County Environmental Health office by Fax:(336-753-1680) Email: , _ __; ____;____ __ ______ Mailing Address: PO Box 848,Mocksville, NC,27028 Incomplete or missing information will delay the delivery of your request..Since we do not presently have an automated system,any little bit of extra information you can provide would greatly aid in the search. Requests will be processed in the order they are received in as timely a manner as possible. Request for Copy of Se tic System Record DATE: /21z46&j-- PIN: 6'8o Z 1 Ll 7517- (Shows an your arcual tax Wu.) REQUESTED BY: � ,r / / PHONE: FAX: �/ E-MAIL: ToMG�G'� /ACSTrlyly �g�� ADDRESS OF PROPERTY: /.T/lo /�e+u✓�iYe C�vaLi �� CITY: SUBDIVISION: LOT#: IS THE SEPTIC SYSTEM INSTALLED? Yes No YEAR SEPTIC INSTALLED OR HOME BUILT/PLACED: l Z �S Stick built ✓ Modular Mobile Vacant Lot NAME OF APPLICANT(if known): NAME OF FIRST OWNER: C. -�. ,o�/ /a.•�.._/ Why doyou need the permit? ✓System Maintenance(pumping,jetting,terralift,distribution and etc...) Real Estate Closing scheduled for Construction(Home replacement,Pool,Deck,Room,Outbuilding or Garage additions,etc.) Real Estate Listing Appraisals General Information/Other(Recent purchase;do not know where system is located,landscaping,etc.,) .r.i.. .5, _ .._ NY .. • _ .1..• is_.. .}• R'...- DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION . *NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name1�,�'– 'P�/�l4� Date `� F f: i J Location r , Subdivision Name Lot No. Sec. or Block No. Lot Size %! House A,*�' Mobile Home _ Business Speculation No. Bedrooms - No. Baths — Yn_ No. in Family _ Garbage Disposal YES ❑ NO �3• Specifications for System: Auto Dish Washer YES ❑ NO ❑ Auto Wash Machine YES Q NO ❑ Type Water Supply *This permit Void if sewage system described below is not installed within 36 months from date of issue. 14 � Nd t = Improvements permit by *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 day of completion. Telephone Number: 704-634-5985. `- 1 1 allatiq Diagram: System Installed by Final Inst Q) J i Zv Certificate of Completion Date - *The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function . satisfactorily for any given period of time. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT ` Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 CONSTRUCTIO SHALL NOT B' N UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Go� Home Phone 1. Permit Requested By-104, y 1d4, nl Tb M FL Business Phone -790p_/00 2. Address 3. Property Owner if Different than Above je rr4 fl dc�o�o.J Address 4. Permit To: a) Install Alter Repair b) Privy Conventional Other Type Ground Absorption c) Sub-Division Sec. Lot Nol;�.;� �� 5. System used to serve what type facility: House Mobile Home Business IndustryOther b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions�3 x-� Bed Rooms 3 Bath Rooms Z Den w/Closet b) If Business, Industry or Other, State: Number of persons served What type business, etc. Estimate amount of waste daily (24 hours) 7. Number and type of water-using fixtures: commodes -7 urinals garbage disposal lavatory 3 showers 3` washing machine dishwasher / sinks 8. a) Type water supply: Public Private Community b) Has the water supply system been approved? Yes No •� 9. a) Property Dimensions b) Land area designated to building site /9 e l'E,/7 E� c) Sewage Disposal Contractor 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? What type? This is to certify that the information is cqrreil to,#m-bewt of my knowledge. Ale Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: _. ID/9�, 1 t DCHD(6-82) �"" - r � r DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 �j SOIL/SITE EVALUATION > Name C AI /CJ� Date Address Lot SizeC/�� FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position �,-,.� S S S PS PS PS '–Q U U U 2) Soil Texture (12-36 in.) Sandy, S S S -S Loamy, Clayey, (note 2:1 Clay) PS PS PS 3) Soil Structure (12-36 in.) S S S S Clayey Soils K PS PS PS U U U 4) Soil Depth (inches) S S S /spy PS PS PS U U U 5) Soil Drainage: Internal S S S PS PS PS `--d U U U External S S S S PS PS PS U U U 6) Restrictive Horizons 7) Available Space S S .S S PS PS PS U U U U 8) Other (Specify) S S S S PS PS PS PS U U U U 9) Site Classification P. , U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: Described by Title Date SITE DIAGRAM t)� DCHD(6-82)