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485 Bell Branch Rd ' OPERATION PERMIT En ice se ny Number 16180 K Davie County Health Department 8 1 +A 210 Hospital Street 1�2�oot bo-e24: P.O.Box 846 umberMocksville, NC 27028; �Phone:336-753-6780 Fax:336-753-1680 T ant: Lynn McCabe Property Owner. Lynn McCabe ress: 445 Bell Branch Rd Address: 445 Bell Branch Rd City: Mocksville City: Mocksville Statefzip: NC 27028 State2ip: NC 27028 Phone#: (862)754-2029 Phone#: (862)754-2029 Property Location & Site Information rI dress/Road#: Subdivision: Phase: Lot: 445 Bell Branch Rd Mocksville NC 27028 Directions Structure: SINGLE FAMILY 601 N left on Liberty Ch Rd to Bell Branch #of Bedrooms: 3 #of People: "Water Supply: NEW WELL 'IP issued by 21x0-Nations,Robert *System Classification/Description: TYPE 11 A CONY SYSTEM(SINGLE-FAMILY OR 480 GPU.OR LESS) *CA issued by: 2140-Nations,Robed Seprolite System? QYes QNo Design Flow: 3 6 0 *Distribution Type: GRAVITY,SERIAL Pump Required? QYes QNo Soil Application Rate: 0 2 a 5 *Pre Treatment: Drain field Nitrification Field 1 . fi , 0 _ Sq' *System Type: INFILTRATOR QUICK 4 STANDARD No.Drain Lines 4 Installer: Brian McDaniel Total Trench Length: 4 0 0 ft. Certification#: Trench Spacing: _ 9 inches O.C. Feet O.C. *EH S: 2140-Nations,Robert Trench Width: 3 Qlnches ffeet Date: 1 2 j 2 8 / 2 0 1 S Aggregate Depth: inches Minimum Trench Depth: 2 4 Inches Minimum Soil Cover. y 1 . a : Inches Approvattatus, a Maximum Tronch l3epth::3 6 pprorred DlapproYed "ny n Inches � -� Maximum Soil Cover. 2 4 Inches r CDP File Number 161800- 1 Septic Tank County ID Number: 132`000.00-W4 Manufacturer ShOaf Let. STB: � Long:760 �------� Gallons: 1000 InstallerBrian McDaniel Date: 0 $ / 1 8 / x 0 1 5 Certification#: *EH S: 2140-Nations.Robert 'Filter Brand: POLYLOK PL-122 With Pipe Adapter ST Marker: El Yes Q No Date: 1 2 / 2 8 / 2 0 1 5 r w Reinforced Tank. Yes ® Nc ❑ 6104 OV 1 Piece Tank: F-1YesR No Jlm �tN irw ova=a o�,rrr. =��;�� s'�r., ,N lam diJaaa i:«Krem; .F ..Scr� r Pump Tank Manufacturer Installer PT: Certification#: Gallons: 'EHS: Date: / / date: Risersealed ❑ Yes ❑ No RiserHeight: ❑ Yes ❑ No (Min.6 in.) pprta Stu 4 7forced Tank: � ❑ Yes ❑ No ❑40 � pr +V+eetIsppr Piece Tank: ❑ Yes ❑ No uu Supply Line CPipe Size: inch diameter Installer Pipe Length: feet Certification#: *Schedule: THS: Pressure Rated ❑ Yes ❑ No Date: / / W atuApproved fittings Yes ❑ No v� StAda T$,-,?,J, � g €3 s r rK AW rn {; ►pp�dYcJ❑ I �e Pump Requirement Pum p Type: Installer. Dosing Volume: - Gal Certification#: Draw Down: Inches THS: *Chain: Date: Valves Accessible ❑ Yes ❑ No W Flow Adjustment Valve ❑ Yes ❑ No Check-valve ❑ Yes ❑ No f"di� � � PVC Unions ❑ "des ❑ No � �� � �Bpi Vent Hole' ❑ yes ❑ No � .Mw ". n {.,,x .µ n aux w; Anti-siphon Hole El Yes 0 NO CDP File Number 161800- 1 County ID Number: g2.000-0"24 Electric E ul ment NEMA 4X Box or Equivalent Q 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: , r Approval Status Ala rm'Audible ❑ Yes ❑ No ❑ Approved❑ Disapproved Alarm Visible ❑ Yes ❑ No 2140-Nations.Robert *Operation Permit completed by: Authorized State Age Date of Issue: 1 a / a 8 / a 9 1 5 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 allconditions of the,Improvement Permit and Construction Authorization.This property is served by a TYPE IIA . 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 Inspection1Maintenance Frequency ByCertified Operator. WA Reporting Frequency By Certified Operator.NIA Rule.1.961 requires that a_Type IV and V seppe,systems designed fora home/business owner must maintain a valid contract with a public management entitywith a certified operator0r 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:Operatan Permit fora`system required to be mainfained bya public.or private management envy,unless the system ownerand 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. *Hand Drawing 41mport Drawing **Site Plan/Drawing attached.** Y ,fr OPERATION PERMIT Davie County Health Department CDP File Number: 161$Ofl a 210 Hospital Street 62-000-00-024 P.O.Boxt3d8 County File Number: Mocksville NC 27028 Date: Oinch DrawingDrawing Type: Operation Permit Scale: . °N A k ft. 1 a �. i .�.,.:� .t .-...nom - _,., .:............ .....:., .....-... k, .,-.:..... ...:.:..,.:.. ......,,,:...,,,....:.....:. :-,....::..::.. .....,: ............ .-gym lrUNO I KULO 1 IUIV AUTHORIZATION *CDP File Number 161800- 1 �"•-S"'F" Davie Count Health Department s2-000-00-024 Y P County ID Number: 210 Hospital Street Evaluated For: NEW P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax: 336-753-1680 1 a / 0 3 a 0 1 9 Applicant: Lynn McCabe Property Owner: Lynn McCabe Address: 445 Bell Branch Rd Address: 445 Bell Branch Rd City: Mocksville City: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 Phone#: (862)754-2029 Phone#: (862)754-2029 Clr Property Location & Site Information Address/Road#: b"✓ Subdivision: Phase: Lot: -Bell Branch Rd Mocksville NC 27028 Directions Structure: SINGLE FAMILY 601 N left on Liberty Ch Rd to Bell Branch #of Bedrooms: 3 #of People: *Water Supply: NEW WELL System Specifications Minimum Trench Depth: a 4 Site Classification: Provisionally suitable Inches Sa ror System? Minimum Soil Cover: 1 a p y OYes (g No Inches Design Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 a a 5 Maximum Soil Cover: a 4 Inches *System Classification/Description: *Distribution Type: GRAVITY-SERIAL TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons *Proposed System: 25%REDUCTION 1-Piece: O Yes i$No Pump Required: O Yes ($No O May Be Required Nitrification Field 1 6 0 0 Sq.ft. Pump Tank: Gallons No. Drain Lines 4 1-Piece: OYes ONo Total Trench Length: 4 0 0 ft GPM—vs— ft. TDH Trench Spacing: _ 9 ®O Inches O.C. Feet O.C. Dosing Volume: Gallons Trench Width: 3 O Inches (9 Feet Grease Trap: Gallons Aggregate Depth: inches Pre-Treatment: O NSF OTS-1 O TS-11 Septic Tank Installer Grade Level Required: 01011 O 111 01V Page 1 of 3 CDP File Number "1 n"I 0LIU - l County ID Number: • ❑ Open Pump System Sheet Repair System Required:0 Yes O No ONO, but has Available Space Repair System Trench Spacing: 9 O Inches O.C. *Site Classification: Provisionally suitable — ®Feet O.C. Trench Width: O Inches Design Flow: 3 6 — 3 ®Feet Soil Application Rate: 0 . a .2 5 Aggregate Depth: inches *System Classification/Description: Minimum Trench Depth: a 4 Inches TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Minimum Soil Cover: 1 a Inches *Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: a 4 Nitrification Field 1 6 0 Inches Sq.ft. No. Drain Lines 4 *Distribution Type: PUMP TO GRAVITY Total Trench Length: 4 0 0 ft Pump Required: ®Yes O No O May Be Required Pre-Treatment: O NSF OTS-I OTS-II *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. Re� 75( *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. Re� 20( 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 same time the Improvement Permit Issued(NCGS 130A336(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 be suspended or revoked(.1937(8)).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: *Issued By: 2140-Nations,Robert Date of Issue: 1 a / 0 3 / a 0 1 4 0-0 Authorized State Agent: Malfunction Log OYes 0 Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 Davie County Health Department CDP File Number: 161800 - 1 210 Hospital Street County File Number: B2-000-00-024 P.O.Box 848 Mocksville NC 27028 Date: 1DI03 D 0 1 4 0 Inch Drawing Drawing Type: Construction Authorization Scale: O Block N/A --------------------- --------------- ----- -------- ---------------------------- 7' ---- --------------------------- ----- O I -------- ----------' --- ----- --- - ----------- ---- --------- ------ -------------------------- .............. ---------------------- -------- ----------------------- --------------------- ----------------------------------- _ _____ _ _—J_-_..._...................... ...................I ----. -wo -------------- --- ------------- ------------------------ - ------------ ------------- F------ ------------------------------------------- ----------------------------------------------------------- Page 3 of 3 n4 r1hr) C� v G s L�� `�." Lb l l CONSTRUCTION AUTHORIZATION • Davie County Health Department 210 Hospital Street CDP File Number: 161800 - 1 P.O.Box 848 B2-000-00-024 Mocksville NC 27028 County File Number: Date: .l.a./ 0 3 / . 0 14 Click below to import an image from an external location: Drawing Type: Construction Authorization Page 3of3 M4 n� �- ---' • IMPROVEMENT PERMIT For office use only `CDP FileNumber 161800-1 :. Davie County Health Department 4 210 Hospital Street County ID Number:B2-000-00-024 r� P.O.Box 848 Evaluated For: NEW Mocksville NC 27028 Township: Phone: 336-753-6780 Fax:336-753-1680 PERLIIT VALID UNTIL: 11/21/2019 "NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: Lynn McCabe Property Owner: Lynn McCabe Address: 445 Bell Branch Rd Address: 445 Bell Branch Rd City: Mocksville City: Mocksville State2ip: NC 27028 State2ip: NC 27028 Phone#: (862)754-2029 Phone 9: (862) 754-2029 Propegy Location & Site Information Fddress/Rojad;k: Subdivision: Phase: Lot: Branch Rd le NC 27028 Directions Structure: SINGLE FAMILY 601 N left on Liberty Ch Rd to Bell Branch #of Bedrooms: 3 #of People: 'Water Supply: NEW WELL S stem Specifications Initlal System `Site Classification: Provisionally Suitable v�-*- Minimum Trench Depth: a 4 Inches Saprolite System? OYes @No Maximum Trench Depth: 4'0 3 6 Inches Design Flow: 3 6 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 0 a a 5 1-Piece: OYes ONo Pump Required: OYes QNo OMay Be Required 'System Classification/Description: TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons LESS) `Proposed System: 25%REDUCTION 1-Piece: OYes ONo Repair System Required:DYes ONO ONO, but has Available Space Repair System "Site Classification: Provisionally Suitable Minimum Trench Depth: a 4 Inches Soil Application Rate: 0 a a 5 Maximum Trench Depth: 3 6 Inches "System Classification/Description: Pump Required: OYes Q No O May be Required TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) 'Proposed System: 25%REDUCTION ' Pagel of 3 CDP Fite Number 161800 - 1 County ID Number: B2-000-00-024 'Site Modifications ❑ Open Fill Sheet No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. 7; =Permit Conditions The issuance of this permit by the Health Department in noway guarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. CAI 7' Site Plan The Improvement Permit shall be valid for 5 years from date of issue with a site plan(means a drawing not necessarily drawn to scale that shows the existing and proposed property lines with dimensions,the location of the facility and appurtenances,the O 0 site for the proposed Wastewater system,and the location of water supplies and surface waters). Plat The Improvement Permit shall be valid without expiration with plat(means a property surveyed prepared by a registered land O surveyor,drawn to a scale of one Inch equals no morethan 60 feet,that includes:the specific location of the proposed facility and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters. Plat also means,for subdivision lots approved by the local planning authority and recorded with the county register of deeds,a copy of the recorded subdivisions plat that Is accompanied by a site plan that Is drawn to scale). The Department and Local Health Department may Impose conditions on the Issuance and may revoke the permits for failure of the system to satisfy the conditions,the rules,or this article This permit is subject to revocation If the site pian,plat,or Intended use changes(NCOS 130A-335(f)).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: *Issued By: 2140-Nations,Robert Date of Issue: a 0 1 4 Authorized state Age : OValid without Expiration? OCreate CA. 01-land Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 • IMPROVEMENT PERMIT 161800 - 1 Davie County Health Department CDP File Number: 210 Hospital Street 82-000-00-024 P.O.Box 848 County File Number: Mocksville NC 27028 Date: Q Inch Drawing Drawing Type: Improvement Permit Scale: OBlock QN/A J� oc I _ _ ! 1 1 1 I I � I I ! � � ' ► 1 I I I 11 I I I f I � 1___i _ �.__ _► _ � N11-1 ;p000A, If I- I I- � 1 I�• i log` 11-r, , - - Li LJ I l _ Page 3 of 3 ♦ y APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Environmental Health—.-', PAID P.O.Box 848/210 Hospital Street T t Mocksville,NC 27028 RECEIVED SWI (336)7534780/Fax(336)753-1680 valuation/Improvement Permit 0 Authorization To Construct(ATC) ❑ Type of ApplicationNew System ❑Repair to Existing System ❑Expansion/Modifmcation of Existing System or Facility ***IMPORTANT""THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. ' APPLICANT INFORMATION Name to be Billed I Contact Person ;SAM Billing Address kp.ik Home Phone 2.- -2AT9— City/State/ZIPBusiness Phone Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Comers Flagged NOTE: A survey plat or site plan must accompany this application. Included:❑Site Plan ❑Plat(to scale) (Permit is ralid for 60 mo ths with •te lan,no expiration with complete plat.) 2�n 1i1,� Owner's Name Yl Y\ PhQne Number 1 �`{ Owner's Address 5 Inn City/Stat e2ip N�CX��1, T� 7(� Property Address City 43 Lot Size t'e`1 Ei 0-1-4! ' Tax PIN# „ 00 0 -0o Zq Subdivision Name(if applicable) Stion/Lot# 1, f Directions To Site:/�t71 1 1-�(_, ( elf(' ' 5 :���Y[�1r�1� If the answer to any of the following questions is'yes",supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes o Does the site contain jurisdictional wetlands? ❑Yes o Are there arty easements or right-of-ways on the site? []Yes gqo Is the site subject to approval by another public agency? ❑Yes)No Will wastewater other than domestic sewage be generated? 0YcsY1Vo IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms 3 #Bathrooms _ Garden Tub/Whirlpool es ❑No Basement es ❑No Basement Plumbing: es ❑No 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: ❑Conventional ❑Accepted ❑Innovative ❑Alterative ❑Other Water Supply Type:❑County/City Water New Well ❑Existing Well 0 Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?❑Yes Alo If yes,what type? 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,the 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 late s d rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and g and flaggin r talo a use/facility location,proposed well location and the location of any other amenities. owner's or a's legal representative signature Site Revisit Charge 3(/'� Client Notification Date: • EHS: Sign given ❑Yes❑No Account# I & I ?00 Revised 11/06 Invoice# V& 75 w 1D'�0 W W/rrfR b •09 117 PC Ml S. 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CRMHC Sriti£-fELT Oes - I.•-••a•as.l'nM table t-s •lq s.•.0'e 1%.fr O—L 37.Or o laa0.ar waver . } - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation I APPLICANT INFORMATION PROPERTY INFORMATION jLynnMcCabe Bell Branch Rd , 862 754-2029 .; B2=000 00=024 65+:Acres. Water Supply: On- rte Well Community !Lblic Evaluation By: Aug r BoringPit �ut ! FACTORS I t 1 2 3 5 6 7 Landscape position Slope% HORIZON I DEPTH a 6 7 Texture group }. ! Consistence r A/ ,' I Structure i Mineralogy HORIZON 11 DEPTH — 7-- ry 109 ! j Texture group 6 C_ 154: I Consistence } y f (. ! Structure Mineralogy HORIZON III DEPTH ! j Texture group ! Consistence Structure 5 Ok CI i Mineralogy ( ! j HORIZON IV DEPTH } I Texture group Consistence I j Structure (. Mineralogy ( I SOIL WETNESS 1 } RESTRICTIVE HORIZON } i i SAPROLTTE 1 I I CLASSIFICATION } i LONG-TERM ACCEPTANCE RATE i SITE CLASSIFICATION: EVALUATI N BY: C'��• s �� LONG-TERM ACCEPTANCERATE: 16,�..7 OTHER(S)PRESENT: REMARKS: LEGEND tandscape Position R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope; CC Concave slope CV- onvex slope T-Terrace FP-Flood plain H f Head slope Texture ! - S-Sand LS-Loamy san SL-Sandy loam L-Loam SI-Silt SICL-Silty clay loam SII.-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silt clay C-Clay CONSISTENCE a'IQ1S1i i VFR-Very friable FR-F 'able FI-Firm VFI-Very firm EFT-Extremely firm NS -Non sticky SS -Slightly sticky S-Sticky VS -Very Sticky I NP-Non plastic SP Slightly plastic P-Plastic VP-Very plastic Structure SC-Single grain M Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogy- 1:1, ineralogy1:1,2:1,Mixed Horizon depth-,In inches I Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface ' Saprolite-S(suitable),U(unsuitable) Soil wetness-Inches from land surface to free water or inches from land surface to soil colors with Aroma 2 or less Classification-S(suitable),PS(provisionally suitable),U(unsuitable) _ ' TTA" T J f rF l F I 45 73 91.: i 1 �J�r_ -J ' 1 91 - 215 f` tttS r L2V , �� O�rviaJtr` AV rC s Printed:Nov 06, 2014 All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the implied warranties of merchantability or fitness for a particular use. 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