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615 Boxwood Church Rd OPERATION PERMIT or ice se nv Davie County Health Department *CDP File Number 198486-1 210 Hospital Street 0600000043 P.O.Box 848 County ID Number. Mocksville NC 27028 Evaluated For'NEW Phone:336.753-6780 Fax:336-753-1680 Township: Applicant: Miranda Bameycastle r roperty Owner. Estate of Ervine E Bameycastle Address: 1399 Main Church Rd ddress: 1399 Main Church Rd City: Mocksville ty, Mocksville State0l): NC 27028 State2ip: NC 27028 Phone#: (336)469-6243 Phone#: (336)469-6243 Pro a Location & Site Information rAddress/Road #: Sub iv' ion: Phase: Lot: pewo0ile NC 27028 Directions Structure: SINGLE FAMILY Hwy 601 South, to Boxwood Church Rd. Land on of Bedrooms: 4 right before Chunn Rd #of People: *Water Supply: NEW WELL *IP Issued by. 240-Nations,Robert 'System Classification/Description: TYPE Il A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140-Nations,Robert Saprolite System? OYes (F)No Design Flow: 4 8 0Distribution Type: GRAVITY-SERIAL Pump Required? OYes t7No Soil Application Rate: 0 3 *Pre Treatment: Drain field (No. trificationField 1 6 0 0 Sq. *System Type: INFILTRATOROUICK4STANDARD Drain Lines 5 Installer: Billy Clayton Total Trench Length: 4 0 0 ft Certification#: 2694 Trench Spacing: — 9 Inches O.C. 2Feet O.C. 'EH S: 2140•Nations,Robert Trench Width: 3 Inches Feet Date: 0 4 / 1 4 / 2 0 1 6 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4Inches ApprovalStatu`s Maximum Trench Depth: 3 6 ® Approved Disapprovetl Inches Maximum Soil Cover: 2 4 Inches CDP File Number 198486 - 1 Septic Tank County ID Namber:, 0600000043 Manufacturer: Shoat Let. STB: 760 Long: . - - - - - Silly Clayton Gallons: 7000 Installer Date: 0 a / 0 5 / a 0 1 6 Certification#: 2694 *EHS: 2140.Nations,Robert *Filter Brand: POLYLOKPL-122 With Pipe Adapter 4 / 1 4 / x 0 1 6 ST Marker. El Yes R1 No Date: Rein forced Tank: ❑ Yes ® NO �►pprovalStatus 1 Piece Tank: El Yes ® No ® Approved❑77, Disapproved Pump Tank Manufacturer. Installer. PT: Certification#: Gallons: *EH S: Date: Date: RiserSealed ❑ Yes ❑ No 'RiserHeght: ❑ Yes ❑ No (Min.6 in.) Approval Status Reinforced Tank:.❑ Yes ❑ NO pproved❑ ❑ A ,Disapproved 1 Piece Tank: [I Yes ❑ No ,:y Supply Line CPipe Size: inch diameter Installer Pipe Length: feet Certification#: *Schedule: *EHS: Pressure Rated ❑ Yes ❑ No Date: Approved fittings ElYes ❑ NO AppcovalStatus ❑ 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 ❑ No Check-valve ❑ Yes ❑ NO A iotoval`Status" PVC unions ❑ Yes ❑ No ❑ Approved❑ Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ Yes ❑ No CDP File Number 198486 - 1 County ID Number: 0600000043 Electric Equipment NEMA 4X Box or Equivalent El Yes El No Installer: Box 12 inches Above Grade El 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 ElYes ❑ No ' Alarm visible El Yes El No ElApprovetl❑ Disapproved 2140-Nation.Robert 'Operation Permit completed by: 0", Zrown Authorized State A Date of Issue: 0 4 / 1 4 / 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 WPE 11 a sewage septic system. Rule A961 requires that a Type TYPE 11 A septic system meet the following criteria: Minimum System Review ByThe Local Health Department: wA Management Entity: OWNER - Minimum System Inspection/Maintenance Frequency ByCertified Operator: NIA 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 homelbusiness owner must maintain a valid contract with a public management entitywith 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 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 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 Olmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT 198486- 1 Davie County Health Department CQP FileNumber: 210 Hospital Street 060M00043 P.O.Box 848 County File Number: Mocksville NC 27028 Date: If Olnch Drawing Drawing Type: Operation Permit Scale. OON A k ft. _� _ _ �P 040(. g eta � � >�� I i ! I I I I CONSTRUCTION For Office Use Only AUTHORIZATION "CDP File Number 198486-1 = Davie County Health Department County,ID Number.0600000043 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 0 3 / a 3 / a 0 a 1 F ant: Miranda Barneycastle Property Owner: Estate of Ervine E Barneycastle ss: 1399 Main Church Rd Address: 1399'Main Church Rd City: Mocksville City: Mocksville State2ip: NC 27028 State2ip: NC 27028 Phone#: (336)469-6243 Phone#: (336)469-6243 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: Pint Road -.Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 601 South, to Boxwood Church Rd. Land on right before Chunn Rd #of Bedrooms: 4 #of People: 'Water Supply: NEW WELL - System Specifications Minimum Trench Depth: a 4 rDesign ssification: Provisionally Suitable Inches e System? Minimum Soil Cover. 1 a y QYes QNo Inches low: 4 8 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 - 3 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: _ 1 0 0 0 Gallons 'Proposed System: 25%REDUCTION 1-Piece: QYes ®No Pump Required: QYes ®No QMay Be Required Nitrification Field 1 6 0 0 Sq.ft. Pump Tank: Gallons No. Drain Lines 4 1-Piece: QYes QNo Total Trench Length: 4 0 0 ftGPM—vs— ft. TDH Trench Spacing: _ 9 Onches O.C. Fet 0C Dosing Volume: _ Gallons Trench Width: Inches 3 _ Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS-I OTS-II Septic Tank InstallerGrade Level Required: QI OII O III OIV CDP File Number 198486 - 1 County ID Number. Q60000OQ43 ❑ Open Pump System Sheet Repair System Required:@Yes ONo ONo, but has Available Space rDesign System Trench Spacing: 9 Inches O. . ification: Provisionally Suitable a Feet O.C. Trench Width: QInches w: 4 8 0 — 3 . @ Feet Soil Application Rate: 0 .1 3 5 Aggregate Depth: inches Minimum Trench Depth: a 4 *System Classification/Description: Inches TYPE II A CONY SYSTEM(SINGLE-FAMILY OR480 GPD OR LESS; Minimum Soil Cover 1 a Inches *Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Nitrification Field 1 7 4 5 Sq.ft. Maximum Soil Cover. a 4 Inches No. Drain Lines 5 *Distribution Type: GRAVITY-SERIAL Total Trench Length: 4 3 6 ft Pump Required: OYes QNo OMay Be Required Pre Treatment: ONSF OTS-I OTS-11 *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 wayguarantees 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 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 130A-336(b)�If the installation has not been completed during the period of validity of the Construction Perm%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(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: *Issued By: 2140-Nations,Robert Date of Issue: 0 3 / a 3 / a 0 1 6 Authorized State Age : Malfunction Log OYeS $` . OHand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION 198486 - 1 Davie County Health Department CDP File Number: 210 Hospital Street 0600000043 P.O.Box 848 County File Number: Mocksville NC 27028 Date: 0 3 / 2 3 / 2 0 16 Q Inch Drawing Drawing Type: Construction Authorization Scale: . QBlock Q N/A l .01 r 30 i CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital street CDP File Number: 198486 - 1 P.O.Box 848 0600000043Mocksviile NC 27028 County File Number. Date: .0 .3 / 23 / 2 0 1 6 Click below to Import an Image from an external location: Drawing Type:Construction Authorization v� D G\� w� POO • - IMPROVEMENT PERMI Fo�oftice.use only 'CDP File Number, 198486-1 . Davie County Health Department 210 Hospital Street County ID Number 06000.00043 P.Q.Box 848 Evaluated For- NEW •`ter..✓- Mocksville NC 27028Township: Phone:336.753-6780 Fax:336-753-1680 PERMIT VALID UNTIL 12/8/2020 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: Miranda Bameycastle Property owner. Estate of Ervine E Bameycastle Address: 1399 Main Church Rd Address: 1399 Main Church Rd City: Mocksville City: Mocksville State)Zlp: NC 27028 State/Zip: NC 27028 Phone#: (336)469-6243 Phone#: (336)469-6243 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: Pint Road Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 601 South, to Boxwood Church Rd. Land on #of Bedrooms: 4 right before Chunn Rd #of People: *Water Supply. NEW WELL System S ecifications nidal S stem 'Sete Classification: Provislonally Suitable Minimum Trench Depth: 2 4 Inches Saprolite System? QYes QNo Maximum Trench Depth: 3 6 Inches Design Flow: 3 6 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 0 . 3 1-Piece: QYes QNo Pump Required: QYes *No,OMayBe 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: QYes ONo Repair System Required:@ Yes ONo ONo, but has Available Space Repair System 'Site Classification: Provisionally Suitable Minimum Trench Depth: a4 Inches SoU Application Rate: 0 - a 3 5 Maximum Trench Depth: 3 6 Inches *System Classification/Description: Pump Required: QYes *No O Maybe Required TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) - -- 'Proposed System: 25%REDUCTION Page 1 of 3 CDP t=ile Number 198486 - 1 County ID Number..0600000043 *Site Modifications ❑ Open Fill Sheet 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 way guarantees the Issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. Site Plan scale improvement Permit shall be vaild for b years from date of Issue with a site plan(means a drawing not necessarily drawn to O scale that shows the existing and proposed property lines with dimensions,the location of the facility and appurtenances,the site fortheproposed Wastewater system,and the location of water supplies and surfacewaters). Plat The improvement Permit shall be valid without expiration with plat(means a property surveyed prepared by a registered land surveyor,drawnto a scale of oneinch 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 tots 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 ruses,"this article This permit is subject to revocation if the site plan,plat,or intended use changes(NCGS 130A435(Q).The person owning orcontroiling the system shall be responsible for assuring compliance with the laws,rules,and permit conditions regarding system location,installation,operation,maintenance6 monitoring, reporting„and repair(.I$W(b)} Applicant/Legal Reps.Signature Required? OYes ONO Appiicant/Legai Reps.Signature' Date: j *Issued By: 2140-Nations,Robert Date of Issue: 1 2 1 0 8 / 2 0 1 5 OValid without Expiration? Authorized State Agent: OCreate CA? *Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 • IMPROVEMENT PERMIT 198486 - 1 • Davie County Health Department CDP File Number: 210 Hospital Street 0500000043 P.O.Box 848 County File Number: Mocksville NC 27028 Date: Qlnch Drawing Drawing Type: Improvement Permit Scale. ' ONiA k �' • �ft. C T-1 p! t d Ilk, IMPROVEMENT PERMIT Davie County Health Department 210 Hospital street CDP Fife N umber: 198486- 1 P.O.Box 848 0600000043 Mocksville NC 27028 County File Number: Date: 101 - 8 / avis Glick below to import an Image from an extemat location:Drawing Type: Improvement Permit APPj WON FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Davie County,Environmental Health P.O.Boa 848/210 Hospital Street Ib ' Mocksville,NC 27028 ` ,(336)753-6780/Fax(336)75371680 �V Application For. J Site Evaluation/Improvement Permit E Authorization To Construct(ATC) ❑Both Type of Application: lal(lew System ❑Repair to Existing System :]Expansion/Modification of Existing System or Facility *'*IMPORTANT"**THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name 1(WUtA &f Ab,CA4k-flContact Person irt1Y1G���Cll Address !VI 11 Home Phone '3 1?'JA let City/State/ZIP NCi Business Phone -'7,5JrV0 Email r1(►�QPn{ytCkS QiI�, c1MGtt ^'� Email: Name on Permit/Aif Dierent than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included:YSite Plan ❑Plat(to scale) (Permit is valid f r 60 onths •h site pia no expiratio with complete pl t.) y(j5Kt Owner's Name £ b 9bne Number v-q0-(oM Owner's Address In hmfo City/State/Zip_M J M,7Vl 9-ID76 Property Address Fit& City_MCM�6 AL Lot Size !Jilh M, Tax PIN# QUOM(1 Subdivision Name(if applicable) S tion/Lot#� —� t, Directions To Site: (pb( Sn Uyitc u C�O`IC tD RuL3Gtt�CC,Ljf%)-,kand on 15�+�'�O��cfe Otunn LA If the answer to any of the following questions is"Yes",supporting doc entation must be attached: Are there any existing wastewater systems on the site? _Yes o Does the site contain jurisdictional wetlands? _Yes No Are there any easements or right-of-ways on the site? _Yes No Is the site subject to approval by another public agency? _Yes No Will wastewater other than domestic sewage.be generated? Yes u IF RESIDENCE FILL OUT THE BOX gLW #People I #Bedrooms #Bathrgems Garden Tub/Whirl ool I IYes INo Basement: :]Yeso Basement Plumbing: ❑Yes 3.14p 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: t#Seats Type system requested: Vonventional ❑Accepted ❑Innovative ❑Altemative ❑Other Water Supply Type:E County/City Water lv/ ew Well ❑Existing Well ❑Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?E Yes i Ao 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 laws and rules. I understand that I arp r ponsible for the proper de tiff tion and labeling of property lines and comers and locating and flagging aking the ho e/fa ity location, roposed el to i and the location of any other amenities. ro erty owner s or o r s egal repr a tative signature Site Revisit Charge 1+L(J Client Notification Date: Date EHS: Sign given I Yes❑No Account# Revised 11/06 Invoice# oo� r� o 39 CQ tJ'a OF .00 0 4 �0 34? I-To CO CO 16 Boxwood Church Rd l t . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Miranda Barneycastle Estate of Ervin Barneycastle 336 469-6243 4.75 Acres Off of Boxwood Church Rd Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2. 3 4 5 6 •7 Landscape position L_ Slope% HORIZON I DEPTH Texture group t L G i. Consistence Structure '1 Mineralogy HORIZON II DEPTH Texture group "::r C, -S L Consistence Structure Mineralogy ,.� HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: l� `> EVALUATION BY: CS ��c A LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: f a f o ca REMARKS: LEGEND Landscape Position R-Ridge S -Shoulder L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope Texture S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm R&I NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky 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 Miner ogalogy 1:1,2:1,Mixed Nato Horizon depth-In inches 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 chroma 2 or less Classification-S(suitable),PS(provisionally suitable),U(unsuitable) LTAR-Long-term acceptance rate-sal/dav/ft2 nr'T-M nvnc M—A..-AN Iry Pa e tt s!/www eda_la com/m/e/ a e 1?stnct a e-luserht3os IansSct-9571d-1 _§ a e1d-1mode-2sm-orsearch-SSP28 .�._�.-p----'- P .co — P 9.Vl N-'P _ ---_ - -P-- ---- --- p-�- - -- — -- -. - L L 57 56 55 54 53 52 51 50 49 18 47 46 45 SS 43 42 41 40 39 38 37 36 35 34 33 32 31 30 29 26 27 26 25 24 23 22 21 20 19 IB 17 1615 14 13 12 11 10 9 B 7 6 S 1 3 2 1 0 ' I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I' I I I I I I I I I I I I I I I I I I 3•-S 112' 61-0 SIB, 5'-3 110' 19•-2' 91-5 318' 11•-3 IIB• 9'-3' 11-S 114• k NP S VERT TWE 33 3648 FhtEO-50 3068-E 3068{ 3068{ GFI s - 6 UMOER TLOOR 1 3660{ 3618 rl%EO 3660-E 1 1 EPS S 4 I Vr•INp u I . 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