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302 Colin Creek Trail OPERATION PERMIT FCDP ice use Only Davie County Health Department umber 138086.1210 Hospital Street as=aoa00407P.4.Box 848 mber. Mocksville NC, 27028. Evaluated,For+ Phone:336-753-6780 Fax:336-753-1680 Township: Applicant: David and Sherry Property Owner. David and Sherry Address: 302 Chestnut Trail Address: 302 Chestnut Trail City: Mocksville City: Mocksville StatefZip: NC 27028 State2ip: NC 27028 Phone#: Phone#: Pro a Location & Site Information r dressfRoad#: Subdivision: Phase: Lot: 302 ChestauPof GD/(?L r6e-JG rot"/ 7 Mocksville NC 27028 Directions Hwy 65 East, left on Comatzer Rd. Turn Right on Structure: OTHER 16nrA) Chestnut Trail, Dead End right at end of road @ Gate #of Bedrooms: ##of People: *Water Supply: NEW WELL *Sys 'IP Issued by. 2taa-Natwns,Robert tem,Classification/Description: TYPE IIA CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140.Nations.Robert SaproliteSystem? 0Yes QNo Design Flow: a 4 0 *Distribution Type: GRAVITY'PARALLEL(eq.d-box) Pump Required? QYes QNo Soil Application Rate: 0 - a *Pre Treatment: Drain field rNInification Field 1 a 0 0 SQ'ft' *System Type: INFILTRATOR QUICK STANDARD rain Lines 3 Installer: Jamie Barnes Total Trench Length: 3 0 0 ft. Certification#: Trench Spacing: — 9 Inches O.C.s Feet O.C. EHS: 2140-Nations,Robert O Trench Width: 3 Inches Feet Date: 0 3 / 1 5 / 2 0 1 5 Aggregate Depth: inches Minimum Trench Depth: 3 Inches Minimum Soil Cover. a 4 Inches Approvat3Statusr Maximum Tronch Depth: .3 6 Inches ® Apprayed C IJlsappr+oved Maximum Soil Cover. 2 4 Inches CDP File Number 938086 - I Septic Tank County ID Number: J6.000.00.107 Manufacturer. shoat Let. STBLong:: 760 Gallons: 1000 Installer. Jamie Bames Date: 1 1 / 0 8 / .2 0 1 4 Certification#: *EH S: *Filter Brand: POLYLOK PL-122 With Pepe Adapter ST Marker. ❑ Yes R No Date: _ 0 , 3 / 1 5 / 2 0 1 S Reinforced Tank: ❑ Yes NO Approval Statu's t Piece Tank: ❑ Yes C No �iOproved❑�Dlsapprovetl r_.. r ' Pump Tank Manufacturer. Installer PT: Certification#: Gallons: 'EH S: Date: / / Date: RiserSealed ❑ Yes ❑ No RiserHeight: E] Yes ❑ NO (Min.6 in.) u .Approval Status r � Reinforced Tank: El Yes ❑ No :❑ Approved® `[3isapplroved 1 Piece Tank: [J Yes El No = `g .. = ' Supply Line Pipe Size: inch diameter Installer. Pipe Length: feet Certification#: *Schedule: *EH S: Pressure Rated ❑ Yes ❑ No Date: Approved fittings [IYes 13 No Approvat Status ❑ Approved❑5 Disapproved X_,-, Pump nt Pump Type: Installer. Dosing Volume: — Gal Certification#: Draw Down: Inches *EH S: *Chain: Date: Valves Accessible ❑ Yes ❑ NO W Flow Adjustment Valve ❑ Yes ❑ NO Check-valve ❑ Yes ❑ No 'App77 rovel'Status' t` PVC unions [I Yes El No ❑, Approved❑ DlsapprOved Vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ Yes ❑ N o CDP File Number 13$086 - 1 County ID Number: J6.000.00.107 Electric Equipment (NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer. 1 Box 12 inches Above Grade ❑ Yes ❑ Na ! 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 Ei-Apio-'ri've"id❑ b-sapp roved Alarm Visible ❑ Yes ❑ NO 2140-Nations.Robert *Operation Permit completed by, Authorized State Agent: Date of Issue: 0 3 / 1 5 / 2 0 1 5 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 rnE n A. sewage septic system. Rule.1961 requires that a Type TYPE 11 A septic system meet the following criteria: Minimum System Review ByThe Local Health Department: NIA Management Entity: OWNER Minimum System InspectionlMaintenance FrequencyByCedifted Operator. NIA Reporting Frequency By Certified Operator.NIA Rule.1961 requires that a Type IV and V septic systems designed for a home/business owner must maintain'a valid contract with a public management entitywith a certified oPeratorora private certified operator for the life ofthe 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 prior to the issuance of an Operation Permit for a system required to be maintained by public_or private management entry,uniess;the system ownerrand certified operatorare the same. The contract shall require specific requirements formaintenance and operation,responsibilities of the owner and'systems operator,provisions that the contract shell be in effect for es long 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 Oimport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT 138086- 1 Davie County Health Department CDP File Number: 210 Hospital Street J6-0 00-00-107 P.O.Box 848 County File Number: Mocksville NC 27028 Date: ! 1 Qlnch Drawing Drawing Type: Operation Permit Scale: . ON A Block Z +' -- -- , l Q � , s I t 't " • CONSTRUCTION For Office Use Only AUTHORIZATION *CDP File Number 138086- 1 •'' Davie County Health Department County ID Number:J6-000-00-107 210 Hospital Street Evaluated For: NEW •`aa. P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax:336-753-1680 0 5 / a 8 / a 0 1 9 Applicant: David and Sherry Property Owner: David and Sherry Address: 302 Chestnut Trail Address: 302 Chestnut Trail City: Mocksville City: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 Phone#: Phone#: Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: 302 Chestnut Trail Mocksville NC 27028 Directions Structure: OTHER Hwy 65 East, left on Cornatzer Rd. Turn Right on Chestnut Trail, Dead End right at end of road @ Gate #of Bedrooms: #of People: *Water Supply: NEW WELL System Specifications Minimum Trench Depth: a 4 CSaproliteSystem? Provisionally suitable Inches Minimum Soil Cover: OYes (&No 1 a Inches2 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: O Yes ®No Pump Required: O Yes ®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. _ 9 ®Feet O.C. Dosing Volume: Gallons Trench Width: _ 3 OInches ADepth: ®Feet Grease Trap: Gallons inches Pre-Treatment: O NSF OTS-1 O TS-11 Aggregate Septic Tank Installer Grade Level Required: 01 011 0111 01V Page 1 of 3 CDP File Number 138086 - 1 County ID Number: J6-000-00-107 - ❑ Open Pump System Sheet Repair System Required:(&Yes ONO ONO, but has Available Space CDesign System Trench Spacing: Q Inches O. . ification: Provisionally suitable — 9 Q9 Feet O.C. Trench Width: Inches w: a 4 0 — 3 Feet Soil Application Rate: 0 - a .� Aggregate Depth: inches Minimum Trench Depth: � 4 *System Classification/Description: Inches TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Minimum Soil Cover: 1 2 Inches LESS) Maximum Trench Depth: 3 6 Inches *Proposed System: 25°/u REDUCTION Maximum Soil Cover: � 4 Inches Nitrification Field ], a 0 0 Sq.ft. No. Drain Lines3 *Distribution Type: GRAVITY-PARALLEL(eq.d-box) 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. R.maidmg 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. Characters 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(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? O Yes ONO Applicant/Legal Reps. Signature: Date: *Issued By: 2140-Nations,Robert Date of Issue: 0 5 / a 8 / a 0 1 4 Authorized State Agent: Malfunction Log OYes ®Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION 138086 - 1 Davie County Health Department CDP File Number: 210 Hospital Street J6-000-00-107 P.O.Box 848 County File Number: Mocksville NC 27028 Date: 05 / .2 8 / ,2014 0Inch Drawing Drawing Type: Construction Authorization Scale: , O Block O N/A Aiv_ --- - - 0- ' -- t---�-y*%_r -- ------------- ------------------ . ------- ---- -- -------------- 01 i -_. ---------�--. -- ........ ... -- _. - - ------................................... --- Page 3 of 3 P1 P2 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: 138086 - 1 P.O.Box 848 CountyFile Number: 16-000-00-107 Mocksville NC 27028 Date: .0.5./ .18 / a 0 14 Click below to import an image from an external location: Drawing Type:Construction Authorization r i 1�8 G `� �• p 1 - C �e 1 Te-) h� 7Pge 3of3 P1 P2 IMPROVEMENT PERMIT For Office Use Only *CDP File Number 138086-1 •�.¢�* Davie County Health Department 210 Hospital Street County ID Number:J6-000-00-107 P.O. Box 848 Evaluated For: NEW Mocksville NC 27028 Township: Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID UNTIL: 5/28/2019 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: David and Sherry -DUNdAtJ Property Owner: David and Sherry _WA�J Address: 302 Chestnut Trail Address: 302 Chestnut Trail City: Mocksville City: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 Phone#: Phone#: Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: 302 Chestnut Trail Mocksville NC 27028 Directions Structure: OTHER Hwy 65 East, left on Cornatzer Rd. Turn Right on #of Bedrooms: Chestnut Trail, Dead End right at end of road @ #of People: Gate *Water Supply: NEW WELL . System Specifications Initial S stem *bite—C,assl ICa Ion: Provisionally Suitable Minimum Trench Depth: oZ 4 Inches Saprolite System? OYes (gNo Maximum Trench Depth: 3 6 Inches Design Flow: a 4 0 Septic Tank: 1 0 0 0 .Gallons Soil Application Rate: 0 a 1-Piece: OYes ®No Pump Required: OYes (9 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 ONo Repair System Required:0 Yes ONo ONo, but has Available Space Repair System *Site Classification: Provisionally suitable Minimum Trench Depth: 2 4 Inches Soil Application Rate: 0 a Maximum Trench Depth: 3 6 Inches *System Classification/Description: Pump Required: OYes ®No O May be Required TYPE II A.CONV SYSTEM'(SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System: 25%REDUCTION Page 1 of 3 CDP File'Number 138086 - 1 County ID Number: J6-000-00-107 *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. °ry 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 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? O Yes ONO Applicant/Legal Reps.Signature: Date: *Issued By: 2140-Nations,Robert Date of Issue: 0 5 / a 8 / a 0 1 4 OValid without Expiration? Authorized State Agent: O Create CA? ®Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 IMPROVEMENT PERMIT Davie County Health Department CDP File Number: 138086 - 1 210 Hospital Street J6-000-00-107 P.O.Box 848 County File Number: Mocksville NC 27028 Date: O Inch Drawing Drawing Type: Improvement Permit Scale: . O Block 0 N/A e 01 •.r 1 6 J G � o Page 3 of 3 P1 P2 IMPROVEMENT PERMIT Davie County Health Department 210 Hospital Street CDP File Number: 138086 - 1 P.O.Box 848 J6-000-00-107 Mocksville NC 27028 County File Number: Date: .0.! . . 8 / 2 0 14 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 Davie County Environmental Health . uIVEIP P.O.Box 848/210 Hospital Street C Mocksville,NC 27028 ��' (336)753-6780/Fax(336)753-1680 Application For: ite Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Type of Application:Xlew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility 'IMPORTANT'*IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name t ��L%_V\.CCX,— Contact Person utar• atvt r Address 0 iJIT&k I Home Phone City/State/ZIP Q Business Phone Email Name on Permit/ATC if iffer nt than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site Ian,no expiration with complete plat.) Owner's Name a Phone Numbe Owner's Address 30 ti City/State/Zip f�l� ' L 76 ZZ Property Address SCU.'N9_ City Lot Size /0 as . Tax PIN# (0-o00-OU"-(0-7 Subdivision Name(if a plicable) S tion/Lot# AA DLections To Site: - — L — ti017 eA 44L mit: t S Specify Problem Occurring: IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms #Bathrooms Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square rootage of Building 9,2 C7 Ig People- #Sinks #Commodes #Showers #Urinals -- Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requestedoonventional ❑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 <No If yes,what type? 'This-is-6 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 Dave County Health Department to conduct necessary inspections to determine compliance with applicable laws and ru . I underst n hat I am responsible for the proper identification and labeling of property lines and corners and loca agging or t e house/facility location,proposed well location and the location of any other amenities. ner's o egal representative signature Site Revisit Charge Date(s): Client Notification Date: DaiJ EHS: PAID ceived b Sign given ❑Yes ❑No Account# Revised 11/06 Invoice# ffil to I � 26 t ♦� µ_,._.re..— -....„,,... ti \\ 1 � l r,f Y ,E i.e r 1 iy s .t02 719 v 13� s Printed:Apr 24, 2014 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 merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie, North Carolina,its 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 data provided by this website. r, DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PRQPERTY INFORMATION Account #: 1S119 030 Tax PIN/EH#: Billed Tobaud +51helrrlU D(, nejaA Subdivision Info: j Reference Name: ] Location/Address: Proposed Facility: Earn Property Size: Date Evaluated: i Water Supply: On-Site Well Community Public .Evaluation By: Auger Boring Pit Cut ` t FACTORS 1 2 3 4 5 6 7 Landscape position Slope% HORIZON I DEPTH Texture group C_ Consistence ;