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150 Cleary Rd OPERATION PERMIT or ice se n v Davie County Health Department 'CDP File Number 123755. 1 �1 210 Hospital Street Ft-000-00-028 r! P.O.Box 848 County ID Number: i 1 Mocksville NC 27028 Evaluated For: NEW Phone:336-753-6780 Fax:336-753-1680 Township: Applicant: Shane Dyson Property owner. Shane Dyson Address: 267 Ijames Church Rd Address: 267 Ijames Church Rd CRY: Mocksville CRY: Mocksville State2ip: NC 27028 State2ip: NC 27028 Phone#: (336)492-5635Phone#: (336)492-5635 Pro a Location 8 Site Information Address/Road#: Subdivision: Phase: Lot: 150 Cleary Road Mocksville NC 27025 Directions Structure: SINGLE FAMILY Hwy 64 West, right on Sheffield, then left on Cleary. #of Bedrooms: 3 #of People: 'Water Supply: EXISTING WELL 'IP Issued by. 2244-Daywalt,Andrew 'System Classification/Description: TYPE II A CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) 'CA issued by: 2244-Daywalt,Andrew Saprolite System? OYes (DNo — Design Flow: "Distribution Type: GRAVITY-SERIAL Pump Required? QYes QNo Soil Application Rate: 0 - 3 'Pre Treatment: Drain field rNo. on Field SQ-ft. 'System Type: INFILTRATOR OUICK 4 STANDARD Lines 3 Installer: Frank Transou s Total Trench Length: 3 0 0 8• Certification#: Trench Spacing: – 9 Inches O.C. Feet O.C. 'EH S: 2325-Machell.Brittany Trench Width: Inches Feet Date: 1 0 / 3 0 / 2 0 1 3 Aggregate Depth: inches Minimum Trench Depth: Inches Minimum Soil Cover. Inches Approval Status.: Maximum Trench Depth: Approved 13 Disapproved Inches Maximum Soil Cover: Inches 123755- 1 Fl-000-oao28 C.BP File Number County ID Number: Septic Tank Manufacturer. Shoal Lat. STB: Long: Gallons: 1.000 Installer Frank Transou Date: 06 / 0 5 / x 0 1 3 Certification#: 'EHS: 2325-eeitchen,Brittany 'Filter Brand: ST Marker. ❑ Yes ❑ No Date: I / Reinforced Tank: ❑ Yes ❑ No Approval Status , P iece Tank: [:1Yes ElNo ElApproved❑ Disapproved Pump Tank Manufacturer. Installer: PT: Certification#: Gallons: 'EHS: Date: / I Date: I I Riser Sealed ❑ Yes ❑ No RiserHeght: ❑ Yes ❑ NO (Min.6in.) Approval Status einforced Tank: ❑ Yes ❑ No ❑ Approved❑ Disapproved 1 Piece Tank: p Yes ❑ No Supply Line Pipe Size: inch diameter Installer: Pipe Length: feet Certification#: 'EHS: 'Schedule: Pressure Rated ❑ Yes ❑ NO Date: I / Approved fittings ❑ Yes ❑ NO Approval Status ❑ Approved❑ Disapproved Pump Requirement 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 ❑ NO Approvat Status PVC unions El Yes ❑ No ❑ Approved❑ Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole 0 Yes ❑ No CDP File Number 123755- 1 County ID Number: Ft-000-'0-028 ,•J Electric Equipment NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer: Box 12 inches Above Grade ❑ Yes ❑ No Certification#: Box Adj.To Pump Tank ❑ Yes ❑ NO Conduit Sealed ❑ Yes ❑ No 'ENS: Pump Manually Operable ❑ Yes ❑ NO *Activation Method: Date: Approval Status Alarm Audible ❑ Yes 13No ❑ Approved❑ Disapproved Alarm Visible El Yes E3No 2325-Mitchell,Brittany *Operation Permit completed by: Authorized State Agent: Date of Issue: 1 0 / 3 0 / 2 0 1 3 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 II A sewage septic system. Rule .1961 requires that a Type TYPE II a septic system meet the following criteria: Minimum System Review ByThe Local Health Department: NIA Management Entity: OWNER Minimum System Inspection/Maintenance Frequency ByCertified Operator: NIA Reporting Frequency By Certified Operator: NIA Rule.1961 requires that a Type IV and V septic systems designed fora hometbusiness owner must maintain a valid contract with a public management entity wkh a certified operator or a private certified operator for the life of the septic system. Rule.1961 requires that Type VI septic systems designed fora 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 entity priorto the issuance of an Operation Permit fora system required to be maintained bya 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 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.** Total Time:(HH-.Ml.1) Activity Code: S-19204-OP issued NEW Type 11 Quick 4 a Hours 0 0 rr mutes OPERATION PERMIT Davie County Health Department CDP File Number: 123755 - 1 210 Hospital Street F1-000-00.028 P.O.Box 848 County File Number. Mocksville NC 27028 Date: 1 0 / 3 0 / 0 1 3 Olnch Drawing Drawing Type: Operation Permit Scale: . OBlock ON/A i nes ii y ---,-.__-...___ .__-- 0 - _. 0 Se J I f ' �- i I f 3 ..i. I E � { I 7 � I '• i I _e. % ! I " CONSTRUCTION For Office Use Only AUTHORIZATION *CDP File Number 123755- 1 Davie County Health Department F1-000-00-028 tY P County ID Number: 4r ' 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 0 / a 1 / a 0 1 8 Applicant: Shane Dyson Property Owner: Shane Dyson Address: 267 Ijames Church Rd Address: 267 Ijames Church Rd City: Mocksville City: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 Phone#: �336'492-5635 Phone#: (336)492-5635 Property Location &Site Information Address/Road#: Subdivision: Phase: Lot: 150 Cleary Road Mocksville NC 27025 Directions Structure: SINGLE FAMILY Hwy 64 West, right on Sheffield,then left on Cleary. #of Bedrooms: 3 #of People: *Water Supply: EXISTING WELL System Specifications Minimum Trench Depth: a 4 rDesign fication: Ps Inches Minimum Soil Cover: ystem? OYes (9 No Inches : 3 6 0 Maximum TrenchDepth: 3 6 Inches Soil Application Rate: 0 3 Maximum Soil Cover: Inches *System Classification/Description: *Distribution Type: GRAVITY-SERIAL 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 0 No Pump Required: OYes ®No O May Be Required Nitrification Field Sq.ft. Pump Tank: Gallons No. Drain Lines 1-Piece: OYes ONo Total Trench Length: 3 0 0 ft GPM—vs— ft. TDH Trench Spacing: Inches O.C. Dosing Volume: Gallons Feet O.C. g Trench Width: Inches Feet Grease Trap: Gallons inches Pre-Treatment: O NSF OTS-1 OTS-11 Aggregate Depth: Septic Tank Installer Grade Level Required: 01011 O III 01V Page 1 of 3 CDP File Number 123755- 1 County ID Number: F1-000-00-028 ❑ Open Pump System Sheet Repair System Required:®Yes ONO O No, but has Available Space CDesign System Trench Spacing: Inches O.C. fication: PS — Feet O.C. Trench Width: O Inches w: 3 6 0 - _ 8Feet Soil Application Rate: 0 3 inches .� Aggregate Depth: *System Classification/Description: Minimum Trench Depth: a 4 Inches TYPE 11 A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Minimum Soil Cover: LESS) Inches Maximum Trench Depth: 3 6 Inches *Proposed System: 25%REDUCTION Maximum Soil Cover: Nitrification Field Inches Sq.ft. No. Drain Lines *Distribution Type: GRAVITY-SERIAL Total Trench Length: 3 0 0 ft Pump Required: Oyes ®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. *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. 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 ®NO Applicant/Legal Reps.Signature: Date: *Issued By: 2244-Daywalt,Andrew Date of Issue: a 1 / a 0 1 3 Authorized State Agent:��, Malfunction Log O Yes ®Hand Drawing O Import Drawing Total Time:(HH:MM) **Site Plan/Drawing attached.** Page 2 of 3 0 0 Hours 3 0 Minutes S-8-CA'S issued-new CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number: 123755 - 1 . 210 Hospital Street F1-000-00-028 P.O.Box 848 County File Number: Mocksville NC 27028 Date: 10 / 21 / ,2013 O Inch Drawing Drawing Type: Construction Authorization Scale: , O Block O N/A 16� �5 jb of \ Page 3 of 3 P1 P2 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: 123755- 1 P.O.Box 848 F1-000-00-028 Mocksville IVC 27028 County File Number: Date: .1.0./ 2 1 / , 0 13 Click below to import an image from an external location: Drawing Type:Construction Authorization Page 3 of 3 P1 P2 • Davie County environmental Health 4? l P.O.Boa 838/210 Ilospital Street Dlocksville,NC 27028 i1 V (336)753-6780/Fax(336)753-1680 V\ IMPROVEMENT PERMIT -F` — m_oo i zw Account #: 990005607 Tax PIN/EH#: 5800-38-0453 Billed To: Shane Dyson Subdivision Info: Address: 267 Ijames Church Road Location/Address: Cleary Road-27028 City: Mocksville Property Size: 26 Acres Reference Name: Proposed Facility: Residential **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. Permit Type: N CNew ORepair ❑Expansion Permit Valid for: R5 Years ONo Expiration Residential Specifications: #Bedrooms _#Bathroom$Z-j #People Basementg Basement plumbingO Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flo-w(GPD):AC� Type of Water Supply: ❑County/City W-Well OCommunity Well Site Modifications/Permit Conditions: S •stem Type LTAR Initial % 1 lu (c,/ .3 Repair Site Plan PAID Date; /0 -11-13 b - a Environmental Health Specialist ,1 ��~' Date i.p.)I-o6 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC RECEIVED Davie County Environmental Health P.O.Box 848/210 Hospital Street OCT 10 2013 Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 DC HEALTH Application For: o Site Evaluation/Improvement Permit ,Authorization To Construct(ATC) o Both Type of Application: -, ew System oRepair to Existing System oExpansion/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 Contact Person _i c�. Ta2.►�P i' AddressHome Phone City/State/ZIP IBJ iyls�-Sc4f gfj , j)C. I S t 3 Business Phone 12- C Email QLW Email: ` Name on Permit/ATC if Different than Ab4e Mailing Address City/State/Zip 3 PROPERTY INFORMATION *Date House/Facility Corners Flagged O NOTE: A survey plat or site plan must accompany this application. Included:o Site Plan oPlat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name Phone Number '33&' `x'09- /y3 Owner's Address City/State/Zip a Property Address City. Lot Size dTax PIN# 5- ?0O- 38- 01153 Subdivision Name(if applicable) Section/Lot# Directions To Site: - d ' -6 o ' o 'LIIQ J If the answer to any of the followii&questions is"Yes",supporting documentation must be attached: Are there any existing wastewater systems on the site? Yes KNo Does the site contain jurisdictional wetlands? _Yes X No Are there any easements or right-of-ways on the site? _Yes XNo Is the site subject to approval by another public agency? _Yes yNo Will wastewater other than domestic sewage be generated? Yes No IF RESIDENCE FILL OUT THE BOX BELOW #People _!y #Bedrooms _ #Bathrooms a•5 Garden Tub/Whirlpool)tYes oNo Basement: es oNo Basement Plumbing: ;d Yes oNo 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:7tonventional oAccepted olnnovative oAlternative oOther Water Supply Type: (County/City Water o New Well oExisting Well o Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?o Yes )f 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. 1 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, 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 qfpe Davie Coun ealth Department to conduct necessary inspections to determine compliance with applicable laws and ru unde tand responsible for the proper identification and labeling of property lines and corners and locating d fl ggin in use/facility location,proposed well location and the location of any other amenities. Property owner's or owner's legal representative signature Site Revisit Charge Date(s): o Client Notification Date: Date EHS: Sign given oYes oNo Account# Revised 11/06 Invoice# • •- " Davie County Environmental Health. 13 ' P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Account #: 990005607 Tax PIN/EH#: 5800-38-0453 Billed To: Shane Dyson Subdivision Info: If 160 Address: 267 Ijames Church Road Location/Address: Cleary Road-27028 City: Mocksville Property Size: 26 Acres Reference Name: Proposed Facility: Residential **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 1 I of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. Permit Type: New ❑Repair ❑Expansion Permit Valid for: 95 Years ❑No Expiration Residential Specifications: #Bedrooms-3-#Bathrooms2-5' People BasementA Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): _ Type of Water Supply: ❑County/City XWell ❑Community Well Site Modifications/Permit Conditions: System Type LTAR Initial '% Vedu zoo/ 1 •3 Repair jaP4 r( "r, •3 Site Plan Environmental Health Specialist Aadma Date ( /l Zow i.p.11-06 I JdtLIC FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Nps 2 Davie County Environmental Health P.O.Bos 848/210 Hospital Street 11Iocksville,NC 27028 EfdVIRONMENIALHEALTN (336)753-6780/Fax(336)753-1680 p„V1E COUNTY a ton For: Si onllm merit Permit Authorization To Construct(ATC) Both Type of Application: ew-STs to -pair to Existing System Expansion/Modification of Existing System or Facility **NAIPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed aH t, 1)t1 Contact Person Billing Address 2& 'q»t e t 4 . Home Phone A5 6-'aq 2• 5-63 City/State/ZIP e- sv' i 2 2 Business Phone Name on Pcmiit/ATC if Different than Above --- _ Mailing Address City/State/zip PROPERTY INFORMATION *Date House/Facilit•Comers Flagged NOTE: A survey plat or site plan must accompurty this application. Incltxled: Site I'an Plat(to scale) (Permit is valid f r 60 mon(Iis with plan.no expiration with complete plat Owners Name ;c4.,( Sh he MAO-, Phone Number L(Ct2-sd 3r Owners Address 2&'7 os G rr City/State/Zip/-10C Irr. ,/c_ 41f 2 'a z5r Property Address ne k K ot City /V 0C_hS-Ville_. Lot Size 26.r C Tax PIN# Z52,5'1&1 ici , �j FOO-3g-- q53 Subdivision Name(ifapplicable) Section/Lot# r C�A��t+Z� Directions To Site: Trine answer to any of the following questions is-ycs!.supporting documentati must be attached. Are there any existing iwstc%%2ter systems on the site'! Yes N Does the site contain jurisdictional wetlands? Ycs Are there any easements or right-of-%mys on the site? Yes o Is the site subject to approval by another public agency? Y. o Will wastewater other than domestic scAvagc be generated? Yes o IF RESIDENCETILL,OUTTHE BOX BELOW #People __ #Bedrooms _„2 #Bathrooms; 2. Garden Tub/Whirlpool Yes No Basement c No Basement Plumbing: Yes o 1F 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: #Scats Type system requested: -Conventional Accepted Innovative Alternative Other Water Supply Type: County/City Water New Wel! cixlEEell Community Well Do you anticipate additions or expansions orthe facility this system is intended to serve! Yes No If yes.what type? This is to certify that the int'ormation provided on this application is true and correct to the tvsl of my knowledge. I understand that any permit(s)or ATC(s)issued hercalier arc subject to suspension or revocation if the site is altered,the intended use changes.or ifthe information submitted in this application is falsified or changed. 1 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 ruig, 1 understand that 1 am responsible for the proper idcntif cation and labeling of property lines and comers and locathi n lagging or. aking the house/lacil ity location.proposed wrll location and the location of any other amenities. - L111--_ Site Revisit Charge Property owner's or m cr's legal representative signature ,,/ a Client Notification(Yate: J - Date k/a4 ^ff �� ke- cj MHS: ��COtt1W1e•LrG.Ti� 0th Sign given Yes No S �1S �s Val Account# Revised 11106 (NA pope4y' Invoice# Septic Area Y ' m Old house (to be removed) rD m W Location of r, ; ' new house F '� '' Existing Well y t DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990005607 Tax PIN/EH#: 5800-38-0453 Billed To: Shane Dyson Subdivision Info: Reference Name: Location/Address: Cleary Road-27028 Proposed Facility: Residential Property Size: 26 Acres Date Evaluated: 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% sex, C_ HORIZON I DEPTH -,q ,_ - Texture group 6L 5C6 _ Consistence Structure Mineralogy , HORIZON II DEPTH _ �,— Texture group Consistence ZAA Structure Mineralogy 5 1' S, HORIZON III DEPTH Jt.'-4p -* 5� Texture group Consistence / 2 Structure C �14CMAZ Mineralogy pig HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE < l SITE CLASSIFICATION: S EVALUATION BY: I L LONG-TERM ACCEPTANCE RATE: 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 CONSISTENCE MOW VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm 3�'et 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 LYQteS . 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