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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 I ' !lam 1 5' i G d+ , , , r_ E � I a I I 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 dN/A l O r t VL J . l r4 � l �� , s �. � p��d _ Imo" ��,�9 � 5 �. 1 i `� I I �°o `� � �y M �� U� �f � 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 � 3 1 i 1 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 Zr)oIV J t----53 v CIO - o � rIVe- rUls T 3Z c' 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) T ren r ___ t 1 L.__1___.r__ ,_..___._._.__ _.._1__ -_._' .. I .__.,....-._ __. __1--J_-1-_.,_ t __ ' (-_•__i.-___--_y-_.-L_-±-_i 1 1 � -1. •�.- ,__ _ __ -.__- _ ._ _ _ _ C� Yr, I ! 5 i 1 I t , 1 L L , lu T ell ZIP J ! i I I� • t � � � � ! `� \i i � >. Iso r} � i � j ..i_. `. _i._ . _ ._._.... r : 1 : .. i 1 1 i j t • _ { t • + • : 1 i I : -•---�_..._ i_.�-- -,''—I -'--7- I• I I - i I- (. .! -t i --!• JL 1 , s I i t _ - f 1 } . ! . I •- -'--• �-- 1 1I A , • I � I _ I- _ LG , i �- o ---r I ---QJ CD V' •�� ti �� l r-� S + r �� 7 7111, { ell V xo ` ,I PO s� FIOO(Z