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109 Buckingham Ln OPERATION PERMIT or se ""- Davie County Health Department *CDP Fite Number 219131 _1 210 Hospital Street P.O. Box 84$ County ID Number. Mocksville NC 27028 . Evaluated For NEW Phone:336-753-6780 Fax:336-753-1680 Township: Applicant: Freedom Homes Property owner: Ronald Peacock Address: 1124 Charlotte Hwy Address: 109 Buckingham Lane City: Troutman , City: Mocksville State2ip: NC 28166 State/Zip: NC 27028 Phone#: (704)876-5866 Phone#: Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: Buckingham Lane Mocksville NC 27028 Directions structure SINGLE FAMILY Hwy 64 W. right on Calahaln Rd. turns to Duke _ Whitaker left onto Buckingham Lane #of Bedrooms: 3 #of People: 'Water Supply: PUBLIC 'IP Issued 6y. 2140-Nations,Robert "System Class if"tiontDescription: = TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140.Nations,Robert SaproliteSystem? C7Yes G)No Design Flow: 3 6 0 'Distribution Type: GRAVITY-SERIAL Pump Required? QYes QNo Soil Application Rate: 0 - a 7 5 'Pre Treatment: Drain field Nil ifimtion Field 1 3 0 9 Sq.ft. 'System Type: INFILTRATOR QUICK 4 STANDARD Na. Drain Lines 3 Installer: Thomas C Frye Total Trench Length: 3 3 0 ft- Certification#: 1069 Trench Spacing: 9 Inches O.C. Feet O.C. 'EH S, 2140-Nations.Robert Trench Width: _ 3 ()Inches Feet Date: 0 3 / 2 0 / 2 0 1 6 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4Approval Status' Inches Maximum Trench Depth: 3 6 Inches © Approved[ Disapproved Maximum Soil Cover: a 4 Inches CDP File Number 219131 - 1 County ID Nurpber: Septic Tank Manufacturer: taylorsvilte Precast Let. STB: 1012 Long: Gallons: 1000 Installer: Thomas C Frye Date: 0 4 / a 7 / a 0 1 6 Certification#: 1069. *EHS: 2140-Nations,Robert 'Filter B rand: POLYLOK PL-122 With Pipe Adapter ST Marker: ❑ Yes 10 No Date: 0 7 / a 0a 0 1 6 / Reinforced Tank: ❑ Yes _ R No ❑ �►pprov-d � Isapprove 1 Piece Tank: ❑ Yes � NO � f Pump Tank Manufacturer. Installer. PT: Certification#; Gallons: *EHS: Date; / / Date: RiserSealed ❑ Yes ❑ NO RiserHeight ❑ Yes ❑ N o CMih,6 in.) Approvat Status �qeTan�k. ��e es ❑ Nod❑ D1 Pie ❑ s .,No Supply line Pipe Size: inch diameter Installer. Pie Length: feet Certification : *Schedule: *EHS: Pressure Rated ❑ Yes ❑ No Date: Approved fittings ❑ Yes ❑ No 1Approval status �❑��pprvv��❑�Dlsapprave� PUMp Requir—emot Pump Type: Installer: Dosing Volume: Gal Certification#: Draw Down: Inches *EHS: *Chair: Date: Varves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check-valve ❑ Yes ❑ No Approvat status PVC Unions El Yes El No ❑ Approved❑ Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ Yes 0 NO CDP File Number 2,19131'- 1 County ID Number: Electric Equipment NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer Box 12 inches Above Grade ❑ Yes ❑ No Certification#: Box Box Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No *EHS: Pump Manually Operable ❑ Yes ❑ No 'Activation Method: Date: Approval Status Alarm Audible ElYes ❑ No Approvetl[j Disapproved Alarm Visible ❑ Yes ❑ No 2140-Nations.Robert *Operation Permit completed by: Authorized State Agent: Date of Issue: 0 7 / a 1 / a 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 TYPE 11'k sewage septic system. Rule.1961 requires that a Type TYPE it 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. 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 entitywith a certified operator or 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 owner and certified operator are the same. The contract shall require specific requirements for maintenance and operation, responsibiities of the owner and systems operator,provisions that the contract shalt 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. OHand Drawing Olmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT Davie County Health Department CDP File Number: 219131 - 1 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: Olnch Drawing Drawing Type: Operation Permit Scale: ON o k 0 __. __ _ __ ______ _ ___ II I --y I eVic/ $'C Q 1,4A f--/ l C5 L7 I I I ( I I I I sal f7j1� t_ CONSTRUCTION For Office use Onlv AUTHORIZATION *CDP File Number 219131--1111: 0-, - ' Davie County Health Department County,ID Number: 210 Hospital StreetEvaluated For NEW P.O. Box 848Township: Mocksville NO 27028 PERMIT VALID UNTIL: Phone:336-753-6780 Fax:336-753-1680 0 6 / a 1 / a 0 a 1 Applicant: Freedom Homes Property Owner: Ronald Peacock Address: 1124 Charlotte Hwy Address: 109 Buckingham Lane City: Troutman City: Mocksville State2ip: NO 28166 State/Zip: NO 27028 Phone#: (704)876-5866 Phone#: Property Location & Site Information Address/Road 9: Subdivision: Phase: Lot: Buckingham Lane Mocksville NO 27028 Directions Structure: SINGLE FAMILY Hwy 64 W. right on Calahaln Rd. turns to Duke Whitaker left onto Buckingham Lane #of Bedrooms: 3 #of People: "Water Supply: PUBLIC System Specifications CFlowMinimum Trench Depth: a 4 : Provisionally Suitable Inches Minimum Soil Cover. 1 a QYes @No Inches 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 . a 7 5 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 (S)No OMay Be Required Nitrification Field 1 3 0 9 Sq.ft. Pump Tank: Gallons No. Drain Lines 3 1-Piece: QYes ONo Total Trench Length: 3 a 7 ft GPM—vs— ft. TDH Trench Spacing: _ 9 Onches Fe t O.C.O.C. Dosing Volume: _ Gallons Trench Width: Inches _ 3 _ ( Feet . Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-II Septic Tank InstallerGrade Level Required: OI Oil 0111 OIV Donn 1 ^f4 CDP File Number 219131 - 1 County ID Number: ❑ Open Pump System Sheet Repair System Required:@Yes ONO ONO, but has Available Space rDesign System Trench Spacing: Onches 0. . ification: Provisionally Suitable — 9 Feet O.C. Trench Width: O Inches w: 3 6 — 3 ©Feet Soil Application Rate: 0 - a 7 5 Aggregate Depth: inches Minimum Trench Depth: a 4 *System Classification/Description: Inches TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. 1 a Inches Maximum Trench Depth: 3 6 Inches *Proposed System: 25°!°REDUCTION Nitrification Field 1 3 0 9 Sq.ft. Maximum Soil Cover. a 4 Inches No. Drain Lines 3 *Distribution Type: GRAVITY-SERIAL Total Trench Length: 3 a 7' ft Pump Required: OYes @No OMay Be Required Pre Treatment: ONSF 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. "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 fora 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)}It the Installation has not been completed during the period of validity of the Construction Permit,the information 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 orConstruction 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 6 / a 1 / a 0 1 6 Authorized State Agent: Malfunction Log OYES @Hand Drawing Olmport 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: 0 6 / 2 1 / .1 0 1 6 Olnch Drawing Drawing Type: Construction Authorization Scale: . OBlock ON/A I I I� � L 'Itj- CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital street CDP File Number: P.O.Box 848 Mocksville NC 27028 County File Number: G 1 ;L�, Date: 0 .6 / 2 1 / 2 0 1 6 Click below to import an Image from an external locAtion: Drawing Type:Construction Authorization vv � �U o Jto v o V W • IMPROVEMENT PERMIT Fo�officeuseonly *CDP File Number 219131 - 1 Davie County Health Department 210 Hospital Street County ID Number. � �. . P.O.Box 848 Evaluated For NEW Mocksville NC 27028 Township: Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID UNTIL' 6/21/2021 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: Freedom Homes r perty Owner. Ronald Peacock Address: 1124 Charlotte Hwy dress: 109 Buckingham Lane City: Troutman y: Mocksville State0l): NC 28166 State/Zip: NC 27028 Phone#: (704)876-5866 Phone#: Property Location & Site Information ('��ddress/Road #: Subdivision: Phase: Lot: Buckingham Lane Mocksville NC 27028 Directions .Structure: . _ SINGLE FAMILY - Hwy 64 W. right on Calahaln Rd. turns to-Duke. #of Bedrooms: 3 Whitaker left onto Buckingham Lane #of People: "Water Supply: PUBLIC System Specifications "Initial System "Site Classification:Ica n: Provisionally Suitable Minimum Trench Depth: 2 4 Inches Saprolite System? OYes @No Maximum Trench Depth: 3 6 Inches Design Flow: 3 6 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 0 . a 7 5 1-Piece: OYes PNo 'System Classification/Description: Pump Required: OYes PNo OMay Be Required TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons LESS) *Proposed System: 25%REDUCTION 1-Piece: OYes t)No Repair System Required:®Yes ONO ONo, but has Available Space Repair System *Site Classification: Provisionally Suitable Minimum Trench Depth: a 4 Inches Soil Application Rate: 0 a 7 5 Maximum Trench Depth: 3 6 Inches u *System Classification/Description: Pump Required: OYes O No O Maybe Required TYPE 11 A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *Pfoposed System: 25%REDUCTION Pagel of 3 CDP File Number 219131 - 1 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. *Permit Conditions The issuance ofthis 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. Site Plan The Improvement Permit shad be wild 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 thefacility and appurtenances,the a site for the proposed wastewater system,and the location of water supplies and surracewaters). Plat The Improvement Permit shall be vaild 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 plan,plat,or intended use changes(NCOS 130A335(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: 0 6 / 2 1 / 2 0 1 6 Authorized State Agent: OValid without Expiration? OCreate CA? ®Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 IMPROVEMENT PERMIT 219131 - 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O.sox 848 County File Number: Mocksville NC 27028 Date: Q Inch Drawing Drawing Type: Imp � , , .rovement Permit Scale: QBlock QN/A - �. -AZZ--w i 1 i e ef I f o ' 4 I O� i � I IMPROVEMENT PERMIT Davie County Health Department 210 Hospital street CDP File Number: 219131 - 1 P.O.Box 848 Mocksville NC 27028 County File Number: Date: 06 / 21 / 2016 Click below to Import an image from an external location:Drawing Type: Improvement Permit CATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC v D:tvte County Enytronmt ot11 Health ��t>R• 1�"' P O I3oe 88/210 Hospital Street`_ - i)IocksYille,NC-27028 (336)753-6780!Fax(336)753-1680 Application For. 7 Site aluation/Improvement Permit C Authorization To Construct(ATC) 0 Both Type of Application:Site 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 !e`Q Contact Person Address%%24 C ar` Home Phone "7 t><f-1 7 G S 8 (o(o. City/State/ZH"-rVov'C h NBusiness PhoneIoY^S.28_7Q6,n Email S�LQ�nQti.ciKerS Q Vr It dvk-Vi Dyy¢S-Ouk1. 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:U Site Plan UPlat(to scale) (Permit i slid for 60 mo the with site plan,no expiration with complete plat.) Owner's Name l�ry�Ae�\� y2ACoGK Phone Number Owner's Address oq L ZK City/State/Zip11ndCV—SV:UQ A1C 27d 8 Property Address I oq City woCJLS J (-Lo— Lot SiaxPIN# 543©gyp. Co(o Subdivision Name(if applicable) Section/Lot# Directions To Site: U5 Coy r Ri- e_ t,tt \alla4' %.Ato labucAA V% S-%-!et S, Co.. Iti C---r - _If the answer to any of the following questions is"Yes",stiplkning documentation must be attached: Are there any existing wastewater systems on the site? &es_NsQ Does the site contain jurisdictional wetlands? Yes]90 Are there any easements or tight-of-ways on the site? Yes.00 Is the site subject to approval by another public agency? Yes 1/!ff Will wastewater other than domestic sewage be generated? Yes IF RESIDENCE FILL OUT THE BOX BELOW - #People �_ #Bedrooms #Bathrooms '1 Garden Tub/Whirlpool I IYes)eNo Basement: 3Yes o Basement Plumbing: IYes Vo IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People #Sims #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested:tz.nventional OAccepted OInnovative ❑Alternative ❑Other Water Supply Type:�unty/City Water ❑New Well ❑Existing Well 7 Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?C Yes 6'No 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. Itinderstandthat I am responsible for the proper identification and labeling of property lines and comers and locating and flagging ors the,1 se/facility 'o ,proposed well location and the location of any other amenities. Site Revisit Charge Property ovine s or owner's legal representative signature Client Notification Date: Date EHS: Sign given I Yes❑No Account# g�� Revised 11/06 Invoice# ` 129 you_ ea --- i 122 TRACT, I f'F310_F�i391 LA '�Y It TRACT 391 4 r' t 7566 TF.Y'.T 2 J.. i 109.\ 701- r i �. o�yrF 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 r, C"r merchantability or fitness for a particular use.Ail users of Davie County's GIS website shall hold harmless the County of Davie,North Carolina,Its U U N� agents,consultants,contractors or employees from any and all claims or causes of action due to or arising out of the use or inability to use the GIS pri nted:May 24 2016 S data provided by this website. s EASEMENT NO APPROVAL REQS + �fEB Sg 2003 \ T\ / SCOTTY.S. P07TS -�AZdlDAME COUNTY p � `\ j // D.B. Sao. PC. 841 / r.S, y84RD a P.8. l0 PC.391' 188 a_1g8 i T� 6.0-T.LWINTANCE ENDS— " - DAME COU • AT B041NDARY LIN 25'rmsTING miruEM COUNTY D.B.337. a �hRSR \` t W TAR 3' 1.\ . - �#scoffs'cRieurCOSTING c, ;:� AADZr aa�R� D B 6L8 PG sst { NN _ ` d / ' LEONARD LEE SB01►PNdR `� NOTES:.B. 890, 1 PG 381PB. 70,tGn 1. TOTAL TRACTS=,,2TRACT 2. TOTAL AC.= 3.399AMA 96'AC ' , AC NX 3 x / 0 g ,N• INCLUDES S.R. 1355.R/W ; -./ �po�. �• TAKEN FROM '.:�` •`�� - = PI Cn Q �RCfS"A', POINT 1 'Q P.9. 10.PG 391 . _:.. & IRON C7< CV i NUMENr LOCATED, WITHI 3. X UNMARKED 4." NO N S GRID fM0 R - tl20N PLAT MAP .: (AXIl ' s ao. EA 2J03 AC. NEW 10 / D0. �+ _ IRON WO \\ ?�td�F ` INCLUDES& S.R1355�R R/W / � B. SHOT BILLY .R ' ...TAKEN FRO,.1 - IXISMC P.11-10,PG.391 /. \\ IRON OWNER BILLY R B SHOFFNER §Z4 148 BUCKINGHXM LN ��bg MOCKSVILLE. N C 27028-0: P (336)'i 492 7518 CLARKS � {. .V,ILLE ':TOWNS- F;Ew � 4 RI6. - IRON vg DAVIE COUNTY, NORTH .0 1tl�(. North C_ 11a - � 5'SOUTH EDGE - - 6berL-2X27 OF PAVEMENT ��`�9' DATE "'APR 21 2015;; ited by �. TAX MAP REF E 2, P/' ' SURVEYED BY A" a subdivision of $paGty that has on G,�- >Esd a 1 Grady;l Tutterow .certify that this plat.wos'drown Aunrrguuch � � � under my,supervision from an;actual survey'made uNE BEARING oisrANc� TUTTERO N >�VE� 0 Lt N 54'53'37'w 54-87 �IOCKSVIt1E, N6 KT Q under'my,supervision (deed descri tion"recorded In N 4738 tT w= 4377 jig D�a'or Book ` Page -,\etc.),�ther Ghat the` L3 N 3172832'w 17.17 33g 75i=581 t>oundarie3;not surveyed are bled i lcated as'drawn L4 N 372832'w : .1233 ( 'category, such as the from Information'found.in PL Book'.— •= Page �NA�rn•'+r{, is N 2955'33'W 31.15 N 'vT Le N 21701.48:W 39.75, ordered survey, or that-the -atio'of precision is In as_j +20.000 - ;til C O Y Q` v N zzo4'os'w -3337 7 100 ani9ion that this Plot was�repared in accordance'with G.S. O.r' Essl `". ' F O ' - L7 N 11720'117'w 70.73 n two the best of my 47-30_as;amende Witness my original eignaturo, fQQO L9 _ N 1759'02'w ,77.14 ` registration number and al this w ::50.35:, 100_ .50 , t) red In a.through d. above.- -.�L_ day of ' F SEAL 1: Lt1: N 10'32'54;W 34.70 A lZ L'L527 = L13 N 0T54'19�W --34.22-- 2 D. 015 . 10 . Pt^S 2527 , i0`�90 o? 3'= u4 N wioie'w. :46.79 SCAE E t :9.9a SURA r•r �. _ L15 N OS59'OY w 70.41 x Registration Number (Seal or Stomp) Registration'Number ii4 �` --w �' U7 N 34'21'37'E tOd B CppRp PtfME '� L17 S 155417-89 W 4" FILE NAME: �r4riur,r AAA SAINT SBARPIEI�f SR3 � :* L � �- NS opu�� � Af 5 G � 5 � 5 � � 75