160 Combs Way OPERATION PERMIT or Ice use n v
Davie County Health Department !CDP.File Number, 120134 1
210 Hospital Street L60o00000202
P.O. Box 848 County ID;Number:
Mocksville NC 27028; Evaluated,For. NEW
Phone:336-753-6780 Fax:336-753-1680 Township:
Applicant: Gary. Livengood Jr. Property Owner: Gary. Livengood Jr.
Address: 170 Tara Court Address: 170 Tara Court
Cky: Mocksville CRY: Mocksville
State/Zip: NC 27028 State2ip: NC 27028
Phone#: (336)654-2157 Phone#: (336)654-2157
Property Location & Site Information
rAddress/Road#: Subdivision: Phase: Lot:
bs Way
le NC 27028 Directions
Structure: 601 Sourht left on 801 left on Will boone Road.
#of Bedrooms: 3
Property on right beside#304
#of People: 4
"Water Supply: PUBLIC
'IP Issued by. 'System Classification/Description:
TYPE 11 A CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
'CA Issued by:
Saprolite System? QYes @f No
Design Flow: 3 6 0 *Distribution Type: GRAVITY.SERIAL Pump Required?
QYes 9No
Soil Application Rate: 0 - 3 *Pre Treatment:
Drain field
rNIdnfication Field 1 a 0 0 Sq.ft. 'System Type: INFILTRATOR QUICK 4 STANDARD
o. Drain Lines 4 Installer. Darrell Salmons
Total Trench Length: 3 0 0 ft. Certification#:
Trench Spacing: _ 9 Qlnches O.C.
r Feet O.C. "EH S: 2140-Nations.Robert
Trench Width: _ 3 Inches
Feet Date: 1 0 / 1 6 / .2 0 1 3
Aggregate Depth: inches
Minimum Trench Depth: 3 0
_ Inches
Minimum Soil Cover. 1 8 Approvai,Status
Inches
r
Maximum Trench Depth:'3 6 ® °Approved Q Disapproved
Inches
Maximum Soil Cover. a 4
Inches
CDP File Number 120134 - 1 Septic Tank County ID Number: L60000000292
Manufacturer. Shoaf Lat.
STB: 760 Long: _
Gallons: 1000
InstallerDarrell Salmons
Date: 07 / 0 1 / a 0 1 3 Certification#:
'EHS: 2140-Nations.Robert
*Filter Brand: POLYLOK PL-122 With Pipe Adapter
Date: 1 0 / l t- / a 0 1 3
ST Marker. El Yes or No
Reinforced Tank: El Yes No
- App`rovai Status ;
1 Piece Tank: ,❑ Yes No [ Approved❑ .Disapproved
Pump Tank
Manufacturer, Installer
PT: Certification#:
Gallons: 'EHS:
Date: Date:
RiserSealed ❑ Yes ❑ No
RiserHeght: ❑ Yes ❑ No (Min.6 in.) ApmvatStratus !
Reinforced Tank: ❑ Yes ❑ No "0"Approved❑ Disapproved
1 Piece Tank: ❑ Yes ❑ NO
Supply Line
CPipe Size: inch diameter Installer
Pipe Length: feet Certification#:
*Schedule: "EHS:
Pressure Rated ❑ Yes ❑ No Data: f
Approved fittings ❑ Yes ❑ No Apokval Status
❑ Approvod❑ Disapproved
Pump Requirement
Pum p Type: Installer.
Dosing Volume: - Gal Certification#:
Draw Down: Inches *ENS:
*Chain: Date: I I
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve ❑ Yes ❑ NO Apprdval:StatiisPVC Unions Q Yes ❑ Na, ❑ Araved❑ Dlsa roved
Veit Hole ❑ Yes ❑ No $: _
Anti-siphon Hole El Yes ❑ NO
OPERATION PERMIT 120134- 1
Davie County Health Department CDP File Number:
210 Hospital Street L60000000202
P.O.Box 848 County File Number:
Mocksville NC 27028 Date:
Q Inch
Drawing Drawing Type: Operation Permit Scale: , oN ick ft.
I �
} } I
I
—17
I
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_I
CDP File Number 120134- 1 County ID Number: L60000000202
Electric Equipment
NEMA 4X Box or Equivalent ❑ Yes ❑ NO Installer.
Box 12 inches Above Grade ❑ Yes ❑ NO
Certification#:
Box Adj. Pump Tank E] Yes ❑ No
Conduit Sealed ❑ Yes ❑ No "EHS:
Pump Manually Operable ❑ Yes ❑ No I ,
"Activation Method: Date:
Approval Status
Alarm Audible ElYes: ❑ No
❑ Approved❑ Disapproved
Alarm Visible ❑ Yes ❑ No1�j
2140•Nations,Robert
*Operation Permit completed by:
Authorized State Agent: Date of Issue: 1 0 1 6 2 0 1 3
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,l5A NCAC'18A.1900 et. Seq.,and all conditions of the Improvement,Pemtit and
Construction Authorization.This property is served by a TYPE It sewage,septic system.
Rule.1961 requires that a Type TYPE I1 A, septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: NIA
Management Entity: OWNER
Minimum System InspectionlMaintenance Frequency ByCertified Operator:
NiA
Reporting Frequency By Certified Operator. NIA
Rule.1.961 requires that a.Type IV and V septic.systems designed fora home/business owner must maintain a valid contract
With a public management entitywith'6 be operator oraI private certified operator;forthe life ofthe septicsystem.
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 entity prior,to the
issuance of an Operation Permit for a system required to be maintained by a public.or private m, tinagement entity,unless the
system ownerand certified operatorare the some. The contract shall require specific requirements formaintenance and
operation,responsibilities of the ownerand;systems;operator;provisions thatthe contract shall be in effect for as long as the
system isln use,and other requirementsforthe;continued proper.performance"ofthe'systemK
. "sheil ats6'66 a condition of
the Operation Permit that subsequent owners of the as execute such a contract.
(Hand Drawing OImport Drawing m..
**Site Plan/Drawing attached.**
• CONSTRUCTION For Office Use Only
AUTHORIZATION 'CDP File Number 120134-1
M ' Davie County Health Department County ID Number: L600000D0202
f a� 210 Hospital Street Evaluated For. NEW
P.O. Box 848
•�:.�• Township:
Mocksville NC 27028 PERMIT VALgD UNTIL:
Phone:336-753-6780 Fax:336-753-1680 a / 0 7 / a 0 1 8
Applicant: Gary.Livengood Jr.
r
erty Owner: Gary.Livengood Jr.
Address: 170 Tara Court ress: 170 Tara Court
City: Mocksville City: Mocksville
StatefZip: NC 27028 StatefZip: NC 27028
Phone##: (336)1,54-2157 Phone#: (33654-2157
Property Location & Site Information
$Ad!dd,rejss/Roa ubdaision• . Phase: Lot:
oone Road A& &000ffP5 �/ fqIsville NC 27028 Directions
Structure: 601 Sourht left on 801 left on Will boone Road. Property
#of Bedrooms: 3 on right beside#304
#of People: 4
`Water Supply: PUBLIC
System Specifications
Minimum Trench Depth: 3 6
(SRe Classification: Inches
Minimum Soil Cover.
prolite System? OYes GNo Inches
esign Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 • 3 Maximum Soil Cover. Inches
*System Class ification/Description: 'Distribution Type: GRAVITY-SERIAL
TYPE 11 A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPO OR LESS) Septic Tank:
1 0 0 0 Gallons
'Proposed System: 25%REDUCTION 1-Piece: OYes QNo
Pump Required: OYes QNo OMay Be Required
Nitrification Field 9 0 0
Sq. ft. Pump Tank: Gallons
No. Drain Lines 1-Piece:OYes QNo
Total Trench Length: . 3 0 0 ft GPM—vs— ft. TDH
Trench Spacing: 9 0 0 Feet O.C. g Inches O.C. Dosin Volume: Gallons
Trench Width: 3 6 Inches
ate Depth:
8Feet Grease Trap: Gallons
- - -
inches Pre Treatment: ONSF OTS-1 OTS-11
Aggregate
Septic Tank Installer Grade Level Required: 01011 OIII OIV
Pagel of 3
7
- 77
7� 10 ,
-7
S-LA,)nn tj
CDP file Number 120134 - 1 County ID Number: L60000000202
❑ Open Pump System Sheet
Repai System Required:OYes ONO ONO, but has Available Space
rDesign
System
Trench Spacing: Inches O.
ification: PS 9 — 0 0 + Feet O.C.
Trench Width: Inches
w: 3 6 0 _ 3 6 Feet
Soil Application Rate: Aggregate Depth:
0 - 3 inches
'System Classification/Description: Minimum Trench Depth: 3 6 Inches
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPO OR LESS) Minimum Soil Cover.
Inches
'Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches
Maximum Soil Cover:
Nitrification Field Inches
9 0 0 Sq.ft.
No. Drain Lines *Distribution Type: GRAVITY-SERIAL
'Total Trench Length: 3 0 0 ft Pump Required: Oyes ONo OMay Be Required
Pre Treatment: ONSF OTS-1 OTS-ll
*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 valld fora person equal to the period of validity of the Improvement Permit,not
to exceed five years,and may be Issued at the sametime 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 fora permit or Construction
Authorization is found to have been Incorrect,falsified or changed,or the site Is attered,the permit or Construction Authorization shall become
Invalid,and may be suspended or revoked(.1937(g)).The person awning 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: 2244-Daywalt,Agrew Date of Issue: a / 3 / a 0 1 3
Authorized State Agent: Malfunction Log Oyes
OHanti Mrawing Olmport Drawing TotalTime:(HH:MM)
**Site Plan/Drawing attached.**
Page 2 of 3 1 Hours_ 0 ea mutes
CONSTRUCTION AUTHORIZATION 2��34�J
Davie County Health Department CDP File Number.
�
ail L;ve210 Hospital Street L60000000202
j` 0TATzQ. a.� � °Q d
ounty File Number.P.O.P.o.Box 848
IloekS til L,wC 770N Mocksville NC 27028 Date; ,0_2./ 0 7 / 2 0 13
33I 35y-7-1570Inch _
Drawing Drawing Type: Construction Authorizatio Scale: (OBlock ft.
QN/A
let
47
-17
IN
a I
Pane 3 of 3
• ' �' IMPROVEMENT PERMIT For Office Use only
r'CDP File Number 120134-1
�•�• Davie County Health Department
►- 210 Hospital Street
unty ID Number.L60000000202
r
P.O.Box 848 Evaluated For: NEW
Mocksville NC 27028 Township:
Phone:336-753-6780 Fax:336-753-1680 PERUIT VALID UNTIL' 217/2018
"NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit.
Applicant: Gary . Livengood Jr. Property Owner: Gary. Livengood Jr.
Address: 170 Tara Court Address: 170 Tara Court
City: Mocksville City: Mocksville
StatefZip: NC 27028 State2ip: NC 27028
111— Phone#: (336)3.54-2157 Phone#: (336)354-2157
Pro a Location & Site Information
FAddress/Road #: Subdivision: Phase: Lot:
ne Road
lle NC 27028 Directions
Structure: 601 Sourht left on 801 left on Will boone Road.
#of Bedrooms: 3 Property on right beside#304
#of People: 4
`Water Supply: PUBLIC
System Specifications
nitial S stem
`Site Classification:
Minimum Trench Depth: 3 6 Inches
Seprolite System? QYes QNo Maximum Trench Depth: 3 6
Inches
Design Flow: 3 6 0 Septic Tank:
1 to 0 0 Gallons
Soil Application Rate: 0 3 1-Piece: QYes ONo
Pump Required: QYes 0N OMay Be Required
*System Classification/Description:
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons
LESS)
`Proposed System; 25%REDUCTION 1-Piece: QYes QNo
Repair System Required:OYes ONO ONO, but has Available Space
CRepair System
`Site Classification: PS Minimum Trench Depth: 3 6 Inches
Soil Application Rate: 0 3 Maximum Trench Depth: 3 6 Inches
'System Classification/Description: Pump Required: (QYes (QNo Q Maybe Required
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR
LESS)
'Proposed System: 25%REDUCTION
Page 1 of 3
CDP File Number 120134 - 1 County ID Number: L60000000202
"Site Modifications p 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 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.
Site Plan The Improvement Permit shad be valid for 5 pears from date of issue with a site plan(means a drawing not necessarily drawn to
O scale that shows the existing and proposed property Imes with dimensions,the location of thefacility and appurtenances,the
site for the proposed Wastewater system,and the location at water supplies and surface waters).
Plat The Improvement Permit shall be wild without expiration with plat(means a property surveyed prepared by a registered land
surveyor,drawn to a scale of one inch equals no more than 60 feet,that Inclundes: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 satisfy the conditions,the rules,or this article.This permit is subjectto revocation n the site plan,plat,or intended
use changes(NCOS 130A-335M).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)�
Applicariftegal Reps.Signature Required? Oyes ONO
Applicant/Legal Reps. Signature: Date:
*Issued By: 2244'Daywait,AndfQ1N Date of Issue: 0 a � 0 7 a 0 1 3
QValid without Expiration?
Authorized State Agent: Q Create CA?
OHand Drawing Olmport Drawing
**Site Plan/Drawing attached.** TotalTime:(HH:111J)
1 Hours, 0 Minutes
Page 2 of 3
Activdv Code:
IMPROVEMENT PERMIT 120134 - 1
Davie County Health Department CDP File Number:
210 Hospital Street L60000000202
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 2 / 7 / 2 0 1 3
Q Inch
DraNvW2 Draw' Type: Improvement P it Scale: pelock
Q N/A
{
f 1
F-H
Lj I --L�
Page 3 of 3
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT'& ATC
EC E A V E Davie County Environmental Health q
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
JAN 1 ? 2013 (336)753-6780/Fax(336)753-1680j,�
Applicatiorl"F' itmprovement Permit C1Authorization To Construct(AT oth
Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing Sys _Hits
***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPT,TC;ANT TNFORMATION
Name Go ry G Z.wino o cd (7r Contact Person
Address r 70 •Tv ea �GF Home Phone 36) .Sy
City/State/ZIP M o G�,S v.'//e ,VG a 70,-Z y Business Phone
Email
Name on Permit/ATC if Different than Above 4X_
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Comers Flagged „e__
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 plan,no expiration with complete plat.)
Owner's Name" ,� w=%000d !Tr Phone Number6
Owner's Address;/l ,G'oo.z c WJ City/State/Zip /" 4/`f oye .27
Property Address City
Lot Size 11-1 ax IN1_6-voo-no-oo.2 -vim
Subdivision Name(if applicable) Section/Lot#
Dir�rections To Site: _>. - Q Q/lr D 2 Q �l
U$ I
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---No
Does the site contain jurisdictional wetlands? Yes---No
Are there any easements or right-of-ways on the site? Yes No
Is the site subject to approval by another public agency? Yes vNo
Will wastewater other than domestic sewage b6 generated? Yes-✓No
�.TF RF,SMF,NC ,FIT T,OT TT THF.BOX RFT,OW
#People #Bedrooms :9 #Bathrooms Garden Tub/Whirl ool es ❑No
Basement: ❑Y s (� Basement Plumbing: ❑Yes t71�10 p
7F NON-RESIDENCE FIT T.,OUT THE BOX BEI,OW
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: .0tonventional ❑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 B-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.
I understand that I am responsible for the proper identification and labeling of property lines and comers and locating and flagging
or stakingAe house/ c" ' ation,proposed well location and the location of any other amenities.
Property owners or own s legal representative signature Site Revisit Charge
Date(s):
—/.,7 Client Notification,Date:
Date EHS:
Sign given ❑Yes ❑No Account# Q
Revised 11/06 Invoice#
360
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• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990006007 Tax PIN/EH#: L60000000202
Billed To: Gary Livengood Subdivision Info:
Reference Name: Location/Address: Will Boone Road-27028
Proposed Facility: Residential Property Size: 7.75 Acres Date Evaluated: 07 L .903
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5. 6 7
Landscape position
Slope% c/so 0
HORIZON I DEPTH
Texture groupe,
Consistence F lZ
Structure i3
Mineralogy
HORIZON R DEPTH
Texture group
Consistence
OPP-
Structure
Mineralogy 1,
HORIZON III DEPTH
Texture group .
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS '
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION PS S
LONG-TERM ACCEPTANCE RATE C .3
SITE CLASSIFICATION: �j EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS:
Landscape Position LEGEND
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
Moist
VFR-Very friable FR-Friable FI-Firm . VFI-Very firm EFI-Extremely firm
3ylt
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
rloi�
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-gal/day/ft2 DCHD 05105(Revised)
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