486 Buck Seaford Rd OPERATION PERMIT F-CDP
Ice use n v -
Davie County Health Department Number 190921 -1210 Hospital Street 5726-9s-1477 71P.O.Box 848 umber.
Mocksville NC 27028 Evaluated For. NEW
Phone:336-753-6780 Fax:336-753-1680 Township::
Applicant: Jordan Cline Property Owner. Jeffrey Smith
Address: 226 W. Church St Address: 454 Buck Seaford Rd
City: Mocksville Cky: Mocksville
State2ip: NC 27028 State0p: NC 27028
Phone#: (336)751-1223 Phone#:
/`
Property Location & Site Information
Address/Road #: T Subdivision: Phase: Lot:
Buck Seaford Road
.Mocksville NC 27028 Directions
Structure: SINGLE FAMILY
Jericho Church Rd, down by South Davie Jr. High,
-
left on Buck Seaford Rd property on right 2 house
..#of Bedrooms: 5 before the end between 454 and 552
#of People: 5
*Water Supply: PUBLIC
*IssuP Ied b 2140-Nations,Robert
*System Classification/Description:
y.
TYPE III A.CONY SYSTEM a 480 GPD(EXCLUDING SFD)
*CA issued by: 2140-Nations,Robert Saprolite System? OYes @No
Design Flow: 6 0 0 Pump Required?
*Distribution Type: GRAVITY-SE.RWL. QYes QNo
Soil Application Rate: 0 a 5 *Pre Treatment:
Drain field
Nrification Field a 4 0 0 S4 *System Type: INFILTRATORQUICK4STANDAR
D
No. Drain Lines 4 Installer: Donny lakey
Total Trench Length: 6 0 0 g• Certification#: 1108
Trench Spacing: — o, Inches O.C.
(«)Feet O.C. *EH S: 2140-Nation,Robert
Trench Width: 3 Inches
Feet Date: 0 5 / 0 4 / 2 0 1 6
Aggregate Depth: inches
Minimum Trench Depth: 3 6
Inches
Minimum Soil Cover4 Approval Status
Inches /
Maximum Trench Depth: 3 6 ® Approved D Disapproved
MaxInches
imum Soil Cover. a 4
Inches
CDP File Number 190921 - 1 Septic Tank County ID Number: 5726.99-1477 `
Manufacturer. Shoaf Lat.
STB: d2 Long:
Gallons:
1250 Installer Donnie Lakey
Certification#: 1108
Date: 0 3 / 0 6 / 2 0 1 6
THS: 2140•Nations,Robert
'Filter Brand: POLYLOK PLA 22 With Pipe Adapter
ST Marker. El Yes ® No
Date: 0 5 / 0 4 / 2 0 1 6
Reinforced Tank: ❑ Yes 0 NO ApprovalStafus
1 Piece Tank: ❑ Yes ® No
® Approved❑�Dlsapproved
Pump Tank
Manufacturer. Installer.
PT: Certification#:
Gallons: *ENS:
Date: / / Date.
RiserSealed Q Yes ❑ No
RiserHeight: ❑ Yes ❑ No (Min.6 in.) - �
Apptavat Status
Reinforced Tank: ❑ Yes ❑ No '❑ Approved❑ Disapproved
1 Piece Tank: ❑ Yes ❑ No
Supply Line
Pipe Size: inch diameter Installer.
Pipe Length: feet Certification#:
"Schedule:
THS:
Pressure Rated ❑ Yes ❑ No Date:
Approved fittings C] Yes El No
Approval Status
y❑ Approved❑ Disapprove
Pump Requirement
Pump Type: Installer:
Dosing Volume: - Gal Certification#:
Draw Down: Inches `ENS:
'Chain:
Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve ❑ Yes ❑ No
Approval Status`°
PVC unions ❑ Yes ❑ No ❑ A roved❑ Dlsa roved
PP Do „
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole ❑ Yes 0 NO
CDP Fite Number 190921 - 1 County ID Number: 5726.99.1477
Electric Equipment
NEMA4XBoxorEquivalent Q Yes ❑ 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 ❑ Yes ❑ No
❑,Approved❑ Disapproved ;
Alarm Visible ❑ Yes ❑ No
2140-Nations.Robert
*Operation Permit completed by: _
Authorized State A Date of Issue: 0 5 / 0 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 as conditions of the Improvement Permit and
Construction Authorization.This property is served by a TYPE III A. sewage septic system.
Rule.1961 requires that a Type -TYPE III A. septic system meet the following criteria: --
Minimum System Review ByThe Local Health Department: WA
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency By Certified Operator:
WA
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 entitywth a certified operatoror a private certified operator for the life of the septic system.
Rule.1961 requires that Type VI septic systems designed fora hometbusiness 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 fora 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 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 Olmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT r
Davie County Health Department CDP File Number: 19921 "
210 Hospital Street 5726-99-14-nP.O.Box 848 County File Number:
Mocksville NC 27028 Date: / !
Olnch
Drawing Drawing Type: Operation Permit Scale: OON A Ic
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CONSTRUCTIONFor office Use Only
AUTHORIZATION 'CDP_ File Number 190921 -1
Davie Count Health Department 5726-99-tan
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 0 3 / 3 0 / 2 0 2 0
Applicant: Jordan Cline Property Owner: Jeffrey Smith
Address: 226 W. Church St Address: 454 Buck Seaford Rd
Cky: Mocksville City: Mocksville
State2ip: NC 27028 State/Zip: NC 27028
Phone#: (336)751-1223 Phone#:
Property Location & Site Information
Address/Road #: Subdivision: Phase: Lot:
Buck Seaford Road
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Jericho Church Rd, down by South Davie Jr. High, left on
Buck Seaford Rd property on right 2 house before the end
#of Bedrooms: 5 between 454 and 552
#of People: 5
"Water Supply: PUBLIC
System Specifications
Minimum Trench Depth: a 4
(Design
Classification: Provisionally Suitable 7nc7hesMinimum Soil Cover.olite System? OYes @No 1aInc
Flow: 6 0 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 . a 5 Maximum Soil Cover: 2 4 Inches
"System Classification/Description: 'Distribution Type: GRAVITY-PARALLEL(eq.d-box)
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
Septic Tank:
1 -2 0 0 Gallons
*Proposed System: 25%REDUCTION 1-Piece: OYes @No
Pump Required: OYes ®No OMay Be Required
Nitrification Field 2 4 0 0 Sq ft Pump Tank: Gallons
No.Drain Lines 5 1-Piece:OYes ONo
Total Trench Length: 6 0 0 n GPM vs— ft. TDH
Trench Spacing: Inches O.C.
9 _ @Feet O.C. Dosing Volume: _ Gallons.
Trench Width: Inches
_ 3 . @Feet Grease Trap: Gallons .
Aggregate Depth: inches
Pre Treatment: ONSF OTS-1 OTS-11
Septic Tank Installer Grade.Level Required: 01 011 OIII OIV
Dsann 1 of Q
CDP Fite Number 190921 - 1 County ID Number..5726-99-1477 '
❑ Open Pump System Sheet
Repair System Required:@Yes ONo ONo, but has Available Space
riDesign
System
Trench Spacing: Inches O. .
ification: Provisionally Suitable — 9 Coo Feet O.C.
Trench Width: Q Inches
w: 6 0 0 — E► Feet
Soil Application Rate: 0 - a 5 Aggregate Depth: inches
`r Minimum Trench Depth: a 4
"System Classification/Description: Inches
TYPE 11 A.CONV SYSTEM(SINGLE-FAMILY OR480GPD OR LESS) Minimum Soil Cover. 1 a Inches
Maximum Trench Depth: 3 6 Inches
*Proposed System: 25%REDUCTION
Maximum Soil Cover: a 4
Nitrification Field a 4 � � Sq.ft. Inches
No. Drain 5
Lines 'Distribution Type: GRAVITY-PARALLEL(eq.d-box)
'
Total Trench Length: 6 0 0 Pump Required: Oyes @No 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.
"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.
This Authorization for Wastewater Systern Construction shall bevalid for a person equal to the period of valldity of the improvement Pe rill,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 Pennk the informatlon submitted in the application fora 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 systern shall be responsible for assuring compliance
with the laws,rules,and permit conditions regarding system location,installation,operation,malntenancA monitoring,reporting and repair
Applicariftegal Reps. Signature Required? Oyes ONo
Applicant/Legal Reps.Signature: Date:
=issued By: 2140-Nations,Robert Date of Issue: . 0 _ 3 / 3 0 / a 0 1 5
Authorized State Agent: t--� �`.. Malfunction Log OYes ;' `.
@Hand Drawing Oimport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department CDP File Number: 190921 - 1
210 Hospital Street
County File Number: 5726-99-1277
P.O.Box 848
Mocksville NC 27028 Date: 0 3 / 3 0 1 2 0 1 5
Q inch
Drawing Drawing Type: Construction Authorization Scale: . 013lock
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IMPROVEMENT PERMIT * For office Use only
CDP'File Number 190921-1
Davie County Health Department
County ID Number:5726-99-1477
210 Hospital Street
P.O. Box 848 Evaluated For:'. NEW
Mocksville NC 27028 Township:
Phone:336-753-6780 Fax: 336-753-1680
PERMIT VALID UNTIL: 3/3/2020
*NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit.
Applicant: Jordan Cline Property Owner: Jeffrey Smith
Address: 226 W. Church StAddress: 454 Buck Seaford Rd
City: Mocksville 7 City: Mocksville
State/Zip: NC 27028 State/Zip: NC 27028
Phone#: (336)751-1223 _) Phone#:
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
Buck Seaford Road
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Jericho Church Rd, down by South Davie Jr. High,
#of Bedrooms: 5 left on Buck Seaford Rd property on right 2 house
#of People: 5
before the end between 454 and 552
*Water Supply: PUBLIC
System Specifications
Initial S stem
*SiteZ assl ICa lOn: Provisionally Suitable
Minimum Trench Depth: c2 4 Inches
Saprolite System? O Yes 9 No
Maximum Trench Depth: 3 6 Inches
Design Flow: 6 0 0 Septic Tank:
1 a 5 0 Gallons
Soil Application Rate: 0 cC 5 1-Piece: OYes ®No
Pump Required: OYes ®No O May Be Required
*System Classification/Description:
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons
*Proposed System: 25%REDUCTION 1-Piece: O Yes O No
Repair System Required:OYes 0 N ONo, but has Available Space
Repair System
*Site Classification: Provisionally suitable Minimum Trench Depth: a 4 Inches
Soil Application Rate: 0 a 5 Maximum Trench Depth: 3 6 Inches
*System Classification/Description: Pump Required: OYes ®No O May be Required
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR
LESS)
*Proposed System:
Page 1 of 3
• 190921 1 5726-99-1477
CDP File Number - County ID Number:
*Site Modifications ❑ Open Fill Sheet
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. R
750
*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. R
750
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
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 more than 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 plan,plat,or Intended
use changes(NCGS 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 O No
Applicant/Legal Reps.Signature: Date:
*Issued By: 2140-Nations,Robert Date of Issue: 0 3 / 0 3 / a 0 1 5
Authorized State A en OValid without Expiration?
g O Create CA?
®Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
IMPROVEMENT PERMIT 190921 - 1
Davie County Health Department CDP File Number:
210 Hospital Street 5726-99-1477
P.O.Box 848 County File Number:
Mocksville NC 27028 Date:
O Inch
Drawing Drawing Type: Improvement Permit Scale: . O O N/Ak --�—��ft.
$7
.K. 2
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1
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Page 3 of 3
P1 P2
IMPROVEMENT PERMIT
Davie County Health Department
210 Hospital Street CDP File Number: 190921 - 1
P.O.Box 848 5726-99-1477
Mocksville NC 27028 County File Number:
Date: .0.3./ 0 3 / . 0 15
Click below to import an image from an external location: Drawing Type: Improvement Permit
Page 3 of 3 P1 P2
-APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
.PAS /, Davie County Environmental Health
P.O.Box 848/210 Hospital Street
pj a Mocksville,NC 27028
ttocetvedb ' (336)753-6780/F;Auth
36)753-1680
�� j 15
Application For:A Site Evaluation/Improvement Permit oran o Construct(ATC) ❑Both
Type of Application: ,yNew System ❑Repair to Existing System ❑Expansion/Modification 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
�� f�
Name �t\T tl C Ir
�n� Contact Person
Address ZZ<, Gil. CAu,cl, S+ Home Phone 336 905—/992
City/State/ZIP Business Phone
Email je11 —rn�� . coy"
Name on ermit/ATC if Dierent than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Fla
NOTE: A survey plat or site plan must accompany this application. Included: Site Plan ❑Plat(to scale)
(Permit is valid for 60 months with si a plan,no expiration with complete'olat.)
Owner's Name ; Phone Number
Owner's Address V5- vck City/State/Zip -yoockgvi t N L ZIOZ8
Property Address 41S-V d-- _5-:5'z ;?R C L ity, Mo c kS v'i//�
Lot Size 10 A et-e S Tax PIN# 3 7 Z(,9 f/L/J
Subdivision Name(if applicable) Section/Lot#
Directions To Site: -T- ri � Le v e� ,
P Dt r h ou a b-e re en le
Specify roble Occurring:
IF RESIDENCE FILL OUT THE BOX BELOW
#People S #Bedrooms _ #Bathrooms Garden Tub/Whirlpool Yes ❑No
Basement:)kYes ❑No Basement Plumbing: Kyes ❑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: Oonventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type:)County/City Water ❑New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes XNo
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 Co ty Health Department to conduct necessary inspections to determine compliance with applicable laws and rules.
I understand that re o i e for the proper identification and labeling of property lines and comers and locating and flagging
or staking the hou ac' ion,proposed well location and the location of any other amenities.
Property owner's or caner legal representative signature Site Revisit Charge
Date(s):
21 l S Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account#
Revised 11/06 Invoice#
• � 1
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SPIKE -�
-------------- 30 EXISTING
159.84 IRON
0\DpCt VNE R/R SPIKE i„l TOTAL- 190.14
2 IXISITNG I 1.94' NORTH WEST FROM �- N $$•03'19' w
IRON ( i, UNMARKED POINT ' z 6.4
cq
O t/1
0�•' ' �'- JEFFREY R. SMITH iZ NEW 20' EASEMENT NEINlZA
3
AS r j OF JAN-23-2015 IRON
D.D. 138, PG. 238
--' N
CA
-------- Io + N 04'26'10° V ANNAIL co
D CAP �►
I 113.46 3
-,,- 5W VNt /+
' cd
\SENO D
�0 Ef -- //+/ SPIKE
-- +// till, (7
` �t-- MICHEAL A. NES
•
+- TRACT 1. i o D.$. 453, PC.
AREA= 10.000 AC.
Z R/R
— - INCLUDES S.R. 1160 R/W NEW _} N 04'26'10' V SPIKE
427.98 �� - IRON 22,94 a' R,R
N 427.9 30• V �D.B. 138. PG. 238 S 68*3'30' E SPIKE I
NEW LINE EXISrrNc 22 S 04'28'10' E P/K
IRON 17.87 NAILmarkedpoint I
S 02'59'45' E�• I CIL road
EXISRNG 10248 r I
N uNE IRON N 66.53130' V
�� gg2,A9 358.90 PLACED NAIL
. TRACT 3 N 76.16 TOTAL= 383.29 IRON/
N �►
AREA= 4.683 AC. 24.39
- JOSEPH J.
R,�R D.D. 197
NEW PIKE
IRON
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
'
Soil/Site Evaluation
I APPLICANT INFORMATION ! PAOPERTY INFORMATION '
Jeffery Smith
Jordan Cline 1 10 Acres
336 909-1999. i Buck Seaford Rd.
5126-99-1477
! ;
Water Supply: On- ite Well Community Public
Evaluation BY Aur Boring /
g g Pit Cut
FACTORS { 1 2 3 5 6 7.
Landscape position L;
Slope%' . i f
HORIZON I DEPTH
Texture group
Consistence
Structure QQ Gk
i
Mineralogy3
! HORIZON H DEPTH —q93
'. Texture group
Consistence -6 1W
Structure
Mineralogy 4 I i
HORIZON III DEPTH 1
Texture group
Consistence
s i
Structure
Mineralogyi !
i
HORIZON IV DEPTH i
Texture group •
Consistence l' j[
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON C i
i' SAPROLITE I
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE 1
SITE CLASSIFICATION: i. EVALUATI! N BY: r •e)i A
( k�
LONG-TERM ACCEPTAN RATE: OTHER(S)PRESENT:- 06m0g.
i R:EMARKS• �
LEGEND i }
Landscape Position I
R-Ridge S -Shoulder ' L-Linear slope FS -Foot slope NI-Nose slope'
CC-Concave slope CV- onvex slope T-Terrace FP--Flood plain H Head slope
Texture i
S Sand LS-Loamy sand SL-Sandy loam L-Loam SI-,Silt
SICL-Silty clay loam SII;-Silty loam CL-Clay loam SCL-dandy clay loam
SC-Sandy clay SIC-Sil clay C-Clay }
lYl4i�t i I
Very friable FR-Friable kI-Firm VFI-Very firm JER Extremely firm
NS Non sticky SS-.Slightly sticky S-Sticky VS -Very Sticky
NP'-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
S..dare ,
SC=Single grain M-M sive CR-Crumb GR-Granular ABK-Ang lar blocky.
i SBK Subangular blocky PL-Platy PR-Prismatic
Mineralogy
1:1,2:1,Mixed
I Horizon depth-In inches
Depth of fill-In inches
Restrictive horizon-Thickness and inches from land surface
Saprolite-S(suitable),U(unsu�table). I
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)
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