1915 Cana Rd CDP File Number 193997 - 1 County ID Number: 5832313789
Electric Equipment
NEMA4XBoxorEquivalent ❑ Yes ❑ NO Installer
Box 12 inches Above Grade ❑ Yes ❑ NO
Certification#:
Box Adj.To Pump Tank ❑ Yes ❑ No
Conduit Sealed ❑ Yes ❑ NO *EHS:
Pump Manually Operable ❑ Yes ❑ NO
*Activation Method: Date:
Approwat Status � ;
Alarm Audible ❑ Yes ❑ No '
❑ Approved❑ Dtsapprove�'
Alarm Visible ❑ Yes ❑ NO
2140•Nates,Robert
*Operation Permit completed by:
Authorized State Agent: Date of Issue: 0 4 1 8 / 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 TYPE It A sewage septic system.
Rule..1961 requires that a Type TY'E II A septic system meet the following criteria:
Minimum System Review By The Local Health Department: NIA
_Management Entity; OWNER
_ -Minimum System InspectionlMaintenance Frequency By Certified Operator:
N/A
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 entitywth a certified operatoror a private certified operator forthe life of the septic system.
Rule.1961 requires that Type VI septic systems designed fora hometbusiness owner must maintain avalid 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 king as the
system is in use,and other requirements for the continued proper performance of the system. It shalt also be a condition of
the Operation Permit that subsequent owners of the systems execute such a contract.
@Hand Drawing 0Import Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT I � ? ! 1Davie County Health Department CDP File Number:
210 Hospital Street 5832313789
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 1 1
O mch
Drawing Drawing Type: Operation Permit Scale: . OONIA k .ft.
. --.
x
e
I I I
I -
I1 _
I
I
1
- p-, ,ax
" 'CONSTRUCTIONFor Office Use Only
AUTHORIZATION
*CDP File.Number 193997.-1
Davie County Health Department County ID Number 5832313789
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 6 / 0 9 / a 0 a 0
Applicant: Beth McCashin Property Owner Beth McCashin
Address: 158 McCashin Lane Address: 158 McCashin Lane
City: Mocksville City: Mocksville
State/Zip: NC 27028 State/Zip: NC 27028
Phone#: Phone#:
Property Location & Site Information
FAddress/Road#: Subdivision: Phase: Lot: 2
ad
e NC 27028 Directions
Structure: SINGLE FAMILY Hwy 601 North right on Cana
#of Bedrooms: 3
#of People: 1
'Water Supply: NEW WELL
System Specifications
Minimum Trench Depth:
Site Classification: Provisionally Suitable a 4 Inches
Minimum Soil Cover.
Saprolite System? OYes OQ No 1 a Inches
Design Flow: 2 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.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
1 0 0 0 Gallons
'Proposed System: 25%REDUCTION 1-Piece: Oyes_ @No
Pump Required: Oyes @No OMay Be Required
Nitrification Field 1 a 0 0 Sq.ft. Pump Tank: Gallons
No. Drain Lines 4 1-Piece:OYes ONo
Total Trench Length: 3 0 0 ftGPM vs— ft. TDH
Trench Spacing: _ 9 Inchtes CC. Dosing Volume: _ Gallons
Trench Width: Inches
3 _ `='Feet Grease Trap: Gallons
Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-ll
Septic Tank Installer Grade Level Required: Ql O�� o��� ow
Dnnn 1 of Z
COP File Number 193997 - 1 County 1D Number.:5832313789
❑ Open Pump System Sheet
Repair System Required:@Yes ONO ONO, but has Available Space
rrDesign
System Trench Spacing: Q Inches 0. .
ification: Provisionally Suitable — 9 Feet O.C.
Trench Width: QInches
w: a 4 0 — . 3 . LJ Feet
Aggregate Depth:
Soil Application Rate: 0 - a inches
`r Minimum Trench Depth: a 4
*System Classification/Description: Inches
TYPE 11 A.CONV 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 a 0 Sq.
Maximum Soil Cover:_ a 4 _
Inches
ft. -
No. Drain Lines *Distribution Type: ,GRAVITY-PARALLEL(eq.d-box)
4
Total Trench Length: 3 � � ft. Pump Required: Oyes (QNo ( May 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 bevalid fora person equal to the period of validity of the Improvement Perml%not
to exceed five years,and may be issued atthe same time the Improvement Permit Issued(NCGS 130A-336(b)).If the installation has not been
completed during the period of vaiidity 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 Constructlon Authorization shall become
Invalid,and may besuspended or revoked(.1937(g)).The person owning or controlling the system shall be responsibleforassuring 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: -OP Date of Issue:
2140-Nations,Robert 0 6 / 0 9 / .2 0 1 5
. - ... - - - - -
op
Authorized State Agent: Malfunction log QYes �, ;
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department CDP File Number:
210 Hospital Street 5832313789
P.O.Box Bas County File Number.
Mocksville NC 27028 Date: 0 6 / 0 9 / 2 0 1 5
OInch
Drawing Drawing Type: Construction Authorization Scale: , ON/Akcc C
ft.
LL -T-III-r--X c-;�i
v,�►-�
a.
it -
CONSTRUCTION AUTHORIZATION '
Davie County Health Department
210 Hospital street CDP File Number:
P.O.Box 84$ 58323137$9
Mocksvitie NC 2702$ County File Number:
Date: 0066 / 0 9 / 2 0 1 5
Click below to Import an Image from an external location: Drawing Type:Cons io uthoriZation
1'
V `
V
t
• IMPROVEMENT PERMIT For office useoniv
"CDP File Number 193997- 1
�-• � Davie County Health Department
- - 5832313789
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 6/9/2020
"NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit.
Applicant: Beth McCashin Property Owner: Beth McCashin
Address: 158 McCashin Lane Address: 158 McCashin Lane
City: Mocksville City: Mocksville
State/ZiP: NC 27028 StatefZip: NC 27028
Phone#: Phone#:
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot: 2
Cana Road
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 601 North right on Cana
#of Bedrooms: 3
#of People: 1
"Water Supply: NEW WELL
System Specifications
nitial S stem
*Site Classification: Provisionally Suitable
Minimum Trench Depth: a 4 Inches
Saprolite System? OYes QNo Maximum Trench Depth: 3 6
Inches
Design Flow: 2 4 0 Septic Tank:
1 0 0 0 Gallons
Soil Application Rate: 0 - a 1-Piece: OYes (j)No
`• Pump Required: OYes ®No OMay Be Required
"System Classification/Description:
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pum p Tank: Gallons
LESS)
*Proposed System: 25%REDUCTION 1-Piece: OYes ONo
Repair System Required:@Yes ONo ONO, but has Available Space
Repair System
"Site Classification: Provisionally Suitable Minimum Trench Depth: 2 4 Inches
Soil Application Rate: - a Maximum Trench Depth: 3 6 Inches
"System Classification/Description: Pump Required: OYes Q No O May be Required
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR
LESS)
' 7posed System: 25%REDUCTION
Page 1 of 3
CDP File Number 193997" 9 County ID Number: 5832313789
*Site Modifications ❑ Open Fill Sheet
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. a
*Permit Conditions
The issuance of this permit bythe Health Department in noway guarantees the issuance of other permits.The permit holder
is responsible for checking With appropriate governing bodies in meeting their requirements. w
Site Plan The improvement Permit shall be valid for b years from date of issue with a site pian(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 forthe proposer!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
surveyor,drawn to a sale of one inch equals no morethan 6o feet,that includes the specific location of the proposed facility
O 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 satisty the conditions,the rules,or this article This permit Is subject to revocation If the site plan,plat,or intended
use changes(NCGS 130A335(1)).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(.1838(b)j
Applicant/Legal Reps.Signature Required? OYes ONO
Applicant/Legal Reps.Signature: Date:
*Issued By: 2140-Nations,Robert Date of Issue: 0 6 / 0 9 / 2 0 1 5
OValid without Expiration?
Authorized State Agent: -@rCreate CA?
@Hand Drawing OlmportDrawing
**Site Plan/Drawing attached.**
Page 2 of 3
IMPROVEMENT PERMIT 193997 - 1
Davie County Health Department CDP File Number:
210 Hospital Street 5832313789
P.O.Box 848
County File Number:
Mocksville NC 27028 Date: / /
Q Inch
Dirawing Drawing Type: Improvement Permit Scale. OBlo k
b
o
IMPROVEMENT PERMIT '
Davie County Health Department '
210 Hospital street CDP File Number: 193997 - 1
P.O.Box 848 5832313789
Mocksvilie NC 27028 County File Number:
Date: 06l09 / 2015
Click below to Import an image from an external location:Drawing Type: Improvement Permit
p�l�ID APPLICATION FOR SITE EVALUATIONMOROVPMENT PERMIT&ATC
Uoxo,UVU4 e$t it Heahk
s ;
(336)753fi78W1FrucC �9539)6$Q:
t Anfistion Far. D Sia otJlmrprwentttd peen t. 0 Aeration To ATC Ocat
TypeorApokakm 8ystsro (IReps$m t?'clstafg Systegt DBxpsruiaNMaditicahoncil Spun;or Farality
'• *"LWOJMNI"'1718 AFPUCA]IVNC tWTBEPRO(R1 WUNI,TSS ALL OF TMRBQUU=
IIVORMATION I3 PROVIGFD.Refer to the IWORMATION BULLE"llt+i fwh m xtkm
APMCAN`A FORMATION
rrmetobaBOW &TI4 fVOY-5hr» ContactPrrsaoj-I4- -
Br"1WgAddress IGR Q-tCA ?" LAME, Homaph= - of
CAy)Sb'4W-rk rKsn'1tE- t<- Bnab=Pbone 33f-9�tP,- tt5
Name om PermiNATi:ifDffmw 1Jtatt Abovm �s 9 7 •3 27�
Mailimg Address cl
PROPERTY INFORMATION 'Date g6useffladMW Camess Flagged S/rills
NOTF- A sm.ey plat or zik plaamest ut q=Y M application. hduled:D See Plm DP140 stale
(Ferauit Is valid for 60 months vh&sitc 0-well Namie�f, n1CC5 plan,no expiratim►with compJek plat)
Phone Number 3-:50
Owmez'sAddress �5 'rYIcCA�Ir,a.� pT /hUcbrt+Itf.nG .276$4 Z
PAY Addrew C Aoji=�'DaPsD Clry Qi
LIA&ZC lZjA-rP4s TbxPI1+�i:D�•10b000( � 1 `PJK483A3i3 784
Subdivisdon Name(if applicable) Settjo�ll,p�t•.�---
DknioasTo5ite
MC C :pn%#Len-
Uft amwet to arty of an f00mving questions Eyes',tv ng d7nerb bs a
Ata there any etmtinggiatrx> om the este? DYes
Does rho she contain jt WkOoml w ? DY4
Are there soy ess�orn&-of-wiys w the Aw EMS '
1:dre sits subject to aptavnl by aoetlow public agency? oyes '
x111 wwtcwvw oUbx lhan demtcstic bs DYes>t
IF RESIDENCE FILL OUT THE BOX BELOW
#Pwplo I I #Bedrooms 2—3 #Bej4v=�_(3wlanTub/WhWpool Dyes
Basement:t]Yes wro BasementFhtmbing: 13Yes Q�
6
IF NON-RESIDENCE FILL OUT THE]BOX BELOW
Type of Facdtft Mvdness Total Square Footep of Bmtldihre #Pwple
#Sidles #wades #Showers #Urinals
Water Usw Wons pfr day) (Attach domamtation of similar f-W icy waax cons ppW
FOODMVICE ONLY: #Seats
Types}rsptm rtquatad: UConw,otior d VAsccptsd Dlhworat[w DAIWrafive 00dw
waw Sw*Type:D Counvicity,Water ac welt til3xiath*Well 0 Commu Sty Won
Do you mulcipate addhim ct eapatxkns of ft fadihy this aygcm h Intended to serve?D Yes tiro
tfycs.wluthrP�
This is b1 oettdy that the fodt>tmationpmvided on this applic4 p is tn¢and¢ohtect to the beat of my knowledge. 1 understand
that o1 ATC(s)ksued bataftet aro subject t+oshape a revocation if the site is slurt4 ft intended use
or if infiormation ilted' is I hereby grant tight of enhy to the AWwIzed
dta Dqvie to iOTOMaoe to desermine compllanea with sppticablo
is=and timt,T and to diV of p AjeAy lines and comers and
1 hY p�apom d well location aW the laaetion of any othoramenitieL
Ftopdty_owmcevorow 1legal repwateuva J esuCharge
5 mss''
CtientNoUfiftwDate:
Dau FNS:
Sigh gr.m DYa CIN. AttourA# c
Ress•d I lA6 lnvoios i
t 'd 6691 'ON Hi1V3H 1diNANON IAN3 30 Wd8I Z E SI4Z '6Z 'J dV
13 i
3 x 5
f r.
-• f� 1
�� 11111,0215 //
' DAVIE COUNTY HEALTH DEPAR
Environmental Health Section
Soil/Site Evaluation
I APPLICANT INFORMATION ; PROPERTY INFORMATION
i
Cana Road LOT#2
Beth McCashin
336 998-5280 i 5832313789
13 Acers
336 978-32798 �I
----------
i Water Supply: Onite Well Community Public
1 Evaluation By: Aug r Boring -Pit Cut
FACTORS j 1 2 3 5 6 7
Landscape position (_
Slope%
HORIZON I DEPTH
Texture group I C e' I
Consistence j 5 i'
S tructure
Mineralogy
HORIZON II DEPTH d �, !
' Texture groupGL !
Consistence f
Structure !
Mineralogyl I
HORIZON III DEPTH I i
Texture groupI !
Consistence
Structure
'
Mineralogy
HORIZON IV DEPTH I
Texture group
Consistence I !
Structure �.
Mineralogy
SOIL WETNESS f I
_R STRICTIVE HORIZON C I
i SAPROLITE
CLASSIFICATION S I
LONG-TERM ACCEPTANCE RATE 0• a . ;t
SITE CLASSIFICATION: IEVALUATI N BY: a
LONG-TERM ACCEPTANCE RATE: V OTHER(S)PRESENT:' 11
I
i REMARKS: t
LEGEND
Landscape Position -
R-Ridge S -Shoulder' ' L-Linear slope FS -Foot slope N-Nose slope'
CC-Concave slope CV- onvex slope T-Terrace FP--Flood plain Hs_Head slope
• exture
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-Sil clay C-Clay
CONSISTF,NCE.
Moist
VVR. Very friable FR-F 'able FI-Firm VFI-Very firm JEFI-Extremely firm
NS-Non sticky SS-.SligF tly sticky S-Sticky VS-Very Stich
NP'-Non plastic SP-Slig tly plastic P-Plastic VP-Very plas,ttc
i
SC Single grain M-Massive CR-Crumb GR-Granular ABK-Ang{lar blocky.
SBK-Subangular blocky L-Platy PR-Prismatic
Mineralogy I
1:1,2:1,Mixed
I Horizon depth-In inches j
Depth of fill-In inches i
Restrictive horizon-Thickness and inches from land surface
1
Saprolite-S(suitable),U(unsui�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),PSrovisionally suitable),U(unsuitable)
T TATI T -__ ,-_- ----------
OPERATION PERMIT
F*CDF
ice use Uni;7
Davie County Health Department Number 193997-1
210 Hospital Street 5832313799
P.O. Box 848 umber
Mocksville NC 27028 Evaluated For. NEW
Phone:336-753-6780 Fax:336-753-1680 Township:
Applicant: Beth McCashin Property Owner. Beth McCashin
Address: 158 McCashin Lane Address: 158 McCashin Lane
City: Mocksville Cky: Mocksville
State2ip: NC 27028 State/zip: NC 27028
Phone#: Phone#:
Property Location & Site Information
Address/Road #: Subdivision: Phase: Lot: 2
1915 Cana Rd
Mocksville NC 27028 Directions
-structure: "SINGLE FAMILY Hwy 601 North right on Cana
#of Bedrooms: 3
#of People: 1
'Water Supply: NEW WELL
*IP Issued by. 2140 Nations,Robert
*System Classification/Description:
TYPE II A CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by: 2140•Nations,Robert Saprolite System? 0 Yes Q No
Design Flow:
.1 - 4 0 GRAVITY-PARALLEL Pump Required?
Distribution Type: (eq'd-box) QYes eNo
Soil Application Rate: 0 a *Pre Treatment:
Drain field
r
on Field 1 2 00Sa•ft• *System Type: EZFLOW EZ 1003T
n Lines 4 Installer: Brett McMahan
Total Trench Length: 3 0 0 Certification#: 1120
Trench Spacing: — 9 ()Inches
O.C.O.C. *EHS:
2140-Nations Robert
Trench Width: 3 Inches
— Feet Date: 0 4 / 1 8 / 2 0 1 6
Aggregate Depth: inches
Minimum Trench Depth: 3 6
_ Inches
Minimum Soil Cover. 4Inches ApptnvaEsStatus
Maximum Trench Depth: 3 6 ® A pproved 'Disapproved
Inches
Maximum Soil Cover, 2 4 Inches
CDP File Number 193997 - 1 Septic Tank County ID Number: 5832313789 -
Manufacturer. Shoaf Lat.
.STB: 760
Long:
Installer. Brett McMahan
Gallons: 1000
Certification#: 1120
Date: 0 1 / 2 8 / .2 0 1 6
THS: 2140-Nations,Robert
*Filter Brand: POLYLOK Dual PL-122 With Pipe Adapter
ST Marker. ❑ Yes IE No Date: 0 4 1 8 l a 0 1 6
Reinforced Tank: E] Yes [O Na % Approve Status50
]
1 Piece Tank: [I Yes [i] NO
Approved❑ Disapproved y
Pump Tank
Manufacturer. Installer.
PT: Certification#:
Gallons: *EHS:
Date: I I Date:
RiserSealed ❑ Yes ❑ No
RiserHeght: ❑ Yes ❑ No (Min.6 in.)
ApprovaCStatus
If.orced Tank: ❑ Yes ❑ No
Approved❑ DisapprovePiece Tank ❑ Yes ❑ No
Supply Line
Pipe Size: inch diameter Installer
Pipe Length: fleet Certification :
*Schedule: THS:
Pressure Rated ❑ Yes ❑ NO Date: I I
Approved fittings ❑ Yes ❑ NO „� Approval,Status
� ❑ Approved❑ Disapproved,
Pump Requirement
CDosing
Type: Installer.
lume: — Gal Certification#:
Draw Down: Inches *ENS.
*Chain:
Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve El Yes ❑ NO Approval StetUS4
PVC unions ElYes ❑ No = ❑ Approved L7 Disapproved
Vent Hole ❑ Yes ❑ NOJA
Anti-siphon Hole [I Yes 0 NO
DeCK
48XIO"
i
Mi
14
I
LL
x
Ifixi
Pot
.wr.r -, .. gp;a T��i. -.,...r*.^=• - ,.� i, ' � -.a,3t a a _ - - �I -
-
s k
20x30
jur_ 1�Sx,1
,
'1
16 . ',
!
..
pi -----------
T
.2 f
1