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631 Buck Seaford Rd OPERATION PERMIT or ice use n y, Davie County Health Department *CDP Fite Number, 198274 1 f 210 Hospital Street P.O.Box 848 County ID Number .�4�. Mocksville NC 27028 Evacuated For NEW, " Phone:336-753-6780 Fax:336-753-1680 Township: Applicant: Chad W Correll Property Owner. Chad W Correll Address: 210 New Hampshire Court Address: 210 New Hampshire Court City: Mocksville City: Mocksville StatefLip: NC 27028 State0p., NC 27028 Phone#: (336)345-4653 1,Phone#: (336)345-4653 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: Buck Seaford Road _ Mocksville NC 27028 Directions Structure: Valley Rd. right on S Davie School Rd. left on Buck _ SINGLE FAMILY Seaford #of Bedrooms: 2 #of People: "Water Supply: PUBLIC *IP Issued by. 2140-Nations,Robert *System Classification/Description: TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 484 GPD OR LESS) *CA issued by: 2140.Nations,Robert Saprotite System? QYes j&Ao Design Flow: a 4 0 * GRAVITY-PARALLEL d-box pump Required? Distribution Type: (�` QYes r&No Soil Application Rate: 0 a 'Pre Treatment: Drain field N1rification Field 1 a 0 0 Sp-ft. *System Type: INFILTRATOR QUICK 4 STANDARD No. Drain Lines a Installer: Donny Lakey Total Trench Length: 3 0 0 ft, Certification#: 1108 Inches O.C. Trench Spacing: 9 Feet O.C. *EH S: 2140-Nations,Robert Trench Width: 3 Inches Feet Date: 0 4 / a 0 / a 0 1 6 Aggregate Depth: inches Minimum Trench Depth: 4 8 Inches Minimum Soil Cover. 3 6 Inches ApprovalS#acus Maximum Trench Depth: 4 8 Inches ® Approved��Dlsapproved Maximum Soil Cover. 3 6 Inches CDP Fite Number 198274 - 1 Septic Tank County ID-Number: Manufacturer: Shoaf Lat. STB: 760 Long: Gallons: 1000 InstallerDonny Latcey Date: 0a / lis 1a0 16 Certification#: 1108 'EHS: 2148-Nations.Robert "Filter Brand: POLYLOKPLA 22With PipeAdapter ST Marker: El Yes p No Date: l a i a 1s Reinforced Tank: i ❑ Yes ❑ No �'�i'/im i�� /0���✓%��� ii/��ii/j/moi Piece Tank: (:1Yes ® No Appro�rcl �Esapprove "' Pump Tank Manufacturer. Installer. PT: Certification#: Gallons: •EHS: Date: Date: / l RiserSealed ❑ Yes ❑ No RiserHeight: ❑ Yes ❑ No (Min.6 in.) ' %�,� App�rovat S#atus Reinforced Tank: ❑ Yes ❑ No ,D�Approved❑�Disap��ver� �� ❑ ..Yes ❑ N a �,y, ,�_��/��� ,.�,,��� �jy„>,,,, Supply Line Pipe Size: inch diameter Installer: Pipe Length: feet Certification#: *Schedule: *EHS: Pressure Rated ❑ Yes ❑ No Date: Approved fittings ❑ Yes ❑ NO Pump RequiEment 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 ElNo %�pprcrvatStatus PVC unions ❑ Yes ❑ No ❑ 1`01, ©t Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ Yes 0 NO CDP File Number 198274 - 1 County ID Number: Electric Equipment NEMAT or Equivalent ❑ Yes ❑ NO Installer. Box 12 Above Grade C] Yes ❑ No Certification#: Boo 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 El Yes ❑ No 2140-Nations,Robert 'Operation Permit completed by Authorized State Agent: ^--�" Date of Issue: 0 4 / 2 0 / 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 ef. Seq.,and as conditions of the Improvement Permit and - Construction Authorization.This property is served by a TYPE 11 A sewage septic system. Rule .1961 requires that a Type TYPE n A. septic system meet the following criteria: Minimum System Review ByThe Local Health Department: NIA Management Entity: OWNER Minimum System Inspection/Maintenance Frequency By Certified Operator: WA 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 entity with a certified operator or 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 entky prior to the issuance of an Operation Permit for a system required to be maintained by a public or private management entty, 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 tong 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. O Hand Drawing OlmportDrawing **Site Plan/Drawing attached.** OPERATION PERMIT 198274 - 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: ! Q Inch Drawing Drawin Type: Operation Permit Scale: , Qt3lock � I I n I I I t I � f CONSTRUCTION . For Office Use Only AUTHORIZATION *CDP File Number 198274- 1 Davie County Health Department 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 1 a 3 a 0 a 0 Applicant: Chad W Correll Property Owner: Chad W Correll Address: 210 New Hampshire Court Address: 210 New Hampshire Court City: Mocksville City: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 Phone#: (336)345-4653 Phone#: (336)345-4653 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: Buck Seaford Road Mocksville NC 27028 Directions Structure: SINGLE FAMILY Valley Rd. right on S Davie School Rd. left on Buck Seaford #of Bedrooms: 2 #of People: *Water Supply: PUBLIC SVstem Specifications Minimum Trench Depth: a 4 Site Classification: Provisionary suitable Inches Minimum Soil Cover: Saprolite System? O Yes No 1 a Inches Design Flow: a 4 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 a Maximum Soil Cover: a 4 Inches *System Classification/Description: *Distribution Type: GRAVITY-PARALLEL(eq.d-box) 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 ®No Pump Required: OYes ®No O May Be Required Nitrification Field 1 a 0 0 Sq.ft. Pump Tank: Gallons No. Drain Lines 3 1-Piece: OYes ONo Total Trench Length: 3 0 0 ft. GPM—vs— ft. TDH Trench Spacing: O Inches O.C. — — g ®Feet O.C. Dosing Volume: Gallons Trench Width: — 3 Inches AFeet Grease Trap: Gallons inches Pre-Treatment: O NSF OTS-1 OTS-11 Aggregate Depth: Septic Tank Installer Grade Level Required: 01 Oil 0111 O IV Page 1 of 3 CDP File Number 198274 - 1 County ID Number: ❑ Open Pump System Sheet Repair System Required:®Yes ONO ONO, but has Available Space CDesign System Trench Spacing: 9 O Inches O. . fication: Provisionally suitable — ®Feet 0.C. Trench Width: O Inches w: a 4 0 — 3 ®Feet Soil Application Rate: 0 a Aggregate Depth: inches .___. *System Classification/Description: Minimum Trench Depth: a 4 Inches TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Minimum Soil Cover: 1 a LESS) Inches *Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Nitrification Field 1 a 0 0 Sq.ft. Maximum Soil Cover: a 4 Inches No. Drain Lines 3 *Distribution Type: Total Trench Length: 3 0 0 ft Pump Required: OYes 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. 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. aame��e 2000 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 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? O Yes O No Applicant/Legal Reps. Signature: Date: *Issued By: 2140-Nations,Robert Date of Issue: 1 1 / a 3 / a 0 1 5 Authorized State Agent: Malfunction Log OYes t ®Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: 11 / .1 3 / .1015 O Inch Drawing Drawing Type: Construction Authorization Scale: , OO Block i t4 � � i- � ; Ian- --- tlz _ _ Nj 0 i 0/4 i ---_ _ ---- __ - ---........--.- Page 3 of 3 P1 P2 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: P.O.Box 848 MocksviI a NC 28 County File Number: Date: .l-1./ .13 / a 0 15 Click below to import an image from an a ernal locati . Drawing Ty :Construction Authorization D v� �juc�C P 1 i �2 Page 3 of 3 P1 P2 APPLICATION FOR SITE EVALUATION/11APROVEMENT PERMIT & ATC Davie County Environmental Health PAW Date: I- 2'I/� P.O.Box 848/210 Hospital Street P /�Mocksville,NC 27028 ` , Recetved b ; 1 (336)753-6780/Fax(336)753-1680 COW L e-- Application For: {<Site Evaluation/Improvement Permit authorization To Construct(ATC) V-Both Type of Application: ❑New 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 l0 / 1 Contact Person Address Z/U )MHome Phone City/State/ZIP 278 Business Phone -?4-5-4653 r—hoA . GO ( &c4rjc.K .con, Email: Name on Permit/ATC if DifTerent than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facili Corners Fla ed NOTE: A survey plat or site plan must accompany this application. Included: Site Plan ❑Plat(to sc e (Permit is valid for 60 months withto plan,no expiration with complete plat.) Owner's Name C�c( � a 6 Phong Number, Owner's Address Z/a iY City/State/Zip C Property Address :54"V D City Lot Size Z0Tax PIN# Subdivision Name(if applicable) Section/Lot# Directions To Site: 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 ✓9 Does the site contain jurisdictional wetlands? Yes ✓No Are there any easements or right-of-ways on the site? _Yes \/-To Is the site subject to approval by another public agency? _Yes ✓�o Will wastewater other than domestic sewage be generated? Yes�io IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms #Bathrooms Garden Tub/Whirlpool ❑Yes o Basement: ❑Yes o Basement Plumbing: ❑Yes ❑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 ❑Alternative ❑Other Water Supply Type:t9dCounty/City Water ❑New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?❑Yes °e!L;C If yes,what type? This is to certify that the information provided on d is 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 charges,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 a proper identification and labeling of property lines and comers and locating and flagging or s ,proposed well location and the location of any other amenities. erty owner's or owne legal representative signature Site Revisit Charge Date(s): Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# J �� Revised 11/06 Invoice# WOW # Page 1 of 1 ___----------------- ------------- "56 ___ _ _W rC' 5521 i a I588 91 r iI a 6o5 Grt i r 50` � t .� 192 200"1 21 Latitu 35�31 �Longit djrf-80`34" 46.33" i ......:. .. !r http://maps2.roktech.net/davie_gomaps/index.html 11/12/2015 Appraisal-Card e Page 1 of 1 DAVIE COUNTY!c- 11112/201S 6:00i3S AM HANES CHABLIS CRAIG HANES MARIE G RMKm/Appeal NIL— Parol:L4400-00-001.03 PLAT:/ UNIQ ID 21130 2201000 ID NO:5736163751 Owner:HANES CHARLIE CRAIG COUNTY TAX(100),FIRE TAX(100) CMD NO.I Of 1 oval Year:2013 Tax Year:2015 26.11 M OFF SUCK SEMOADLOT 3 26.]50 AC SRC-Inspedwn nUe by 28 0103/16/2.,06005)ERICMO TV-06 Cl- FR-12 EX- AT- UST ACRON 20130206 CONSTRUCTION DETAIL MARKET VALUEDEPRECIATION CORRELATION OF VALUE OTAL POINT VALUE EN. BASE . BUILDING USE MOD Area UAL RATE RCN EYB AYB AEDENCE TO ADJUSTMENTS 97 1 00 1 1 1 GOOD EPR.BUILDING VALUE-GRD OTAL ADJUSTMENT TYPE:Vacant EPR.OB/XF VALUE-GRD ACTORARKET LAND VALUE-GRD 71,6 OTAL QUALITY INDEX STYLE; OTAL MARKET VALUE-CARD 7363 OTAL APPRAISEDVALUE-GRD 71,63 OTAL APPRAISED VALUE-PARCEL 7163 OTAL PRESENT USE VALUE-PARCEL 11,5 OTAL VALUE DEFERRED-PARCEL 56,75 OTAL TAXABLE VALUE-PARCEL 1185 PRIOR ILDING VALUE %FVALUE D VALUE 71,63 RESENT USE VALUE 13,02 EFERREDVALUE SB,61 OTAL VALUE 71 63 PERMIT CODE DATE NOTE I NUMBER AMOUNT WT:wTRSMD: SALES DATA FF. ECORD ATE DEEDINDIGTESALES —KA.E 0. TYPE PRICE 996 069 7 101 WD• U V 139 - 111 350 1 98 WD X V HEATED AREA NOTES ROM GREEN NEWET SUBAREA UNIT CCMG% SUE ANN DEP K OS/XF DEPR GS RPL OD Al UCRIPTIO OU NTT PRICE GOND LOG PAR Y FY RAT[ V COND VALUE TYPE AREA CS OTAL OB%F VALUE REPLACE UBAREA DIALS UILDING DIMENSIONS AND INFORMATION DIMUS NTS IGMEST NDD NOW MOTES LAND TOTAL NO BEST USE LOCALFBON DEITX/ END GOND RF AC LC TO OA UNIT LAND UNP TOTAL ADJUSTED LAND OVERRIDE LANG SE CODE ZONING TACE E SIZE MOD FACT OT TYPE PRICE UNITS TYP ADJST UNIT PRICE VALUE VALUE NOTES URALAC 0120 0 0 0.9800 1 0.1200 12-16,00.10.20 PD 6,500. 26.71 AC 0.412 2,678. 7163 NP CR FL OTAL MARKET LAND DATA 26.)1 71 63 E5000 0 0 1.0000 5 1.0000 2,6)8. 3.71 AC 1.00 2,6]e. 100 NQ 621000 1.0000 5 1.000 2J0. 10.50 AC 1. 2)0. 283631000 1.0000 5 1.0000 230. 3.51 AC 1. 230. BO 611000 1.0000 5 1.0000 130. 5.99 AC 1. 130. 116 ENT USE DATA 26.]1 11,85 http://maps.daviecountync.gov//ITSNet/AppraisalCard.aspx?parcel=L40000000103 11/12/2015 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION W_ 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 ) J D Texture group 0 Consistence Al Structure 14 MineralogyG 0� HORIZON II DEPTH Texture group 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: ✓ EVALUATION BY: y LONG-TERM ACCEPTANCE RATE: a OTHER(S)PRESENT: 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 CONSISTF.NC'F. Maht VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm 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 Mineralogy 1:1,2:1,Mixed. 1Y4ts<S .. 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-eal/dav/ft2 r+rur�nc�nc ane..:,va. vst� ICA vj Ko fo — ei�$i. 771 - ' 1Y I51I f W --- •,. ,ry _ — —�.-. _ •�� ;� _. t4.C-1v1f vxr—FUS =l° G%q,l+ �QD g3 r a s +s4 _ • i IN I ; ,Is y /® ® � I - N ��a © rtalf� U�ut<D�7 :=u; � _- - . .. .® z'DSi•1dW£1`.7tn�. .-.- ....�_..- . 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