885 Cornatzer Rd OPERATION PERMIT or fice use, INIV
fes. Davie County Health Department *CDP File Number 19305-1
210 Hospital Street 5758884597
P.O. Box 848 County ID Number
Mocksville NC 27028 Evaluated For. REPAIR
Phone:336-753-6780 Fax:336-753-1680 Township
Applicant: Daniel York Pearl Property owner. Daniel York Pearl
Address: 153 George Jones Road Address: 153 George Jones Road
City: Mocksville City Mocksville
StatefZip: NC 27028 'State2ip: NC 27028
Phone#: Phone#:
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
885 Cornatzer Road
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 64 East left on Cornatzer R. on the left corner of
Cornatzer and George Jones Rd
#of Bedrooms:
#of People:
*Water Supply: WA
*IP Issued by.
*System Classification/Description:
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by: 2140-Nation$,Robert
SaproliteSystem? OYes @No
Design Flow: a 4 0 *Distribution Type: GRAVITY-PARALLEL(eq.d-box) Pump Required?
QYes (DNo
Soil Application Rate: 0 a 7 5 *Pre Treatment:
Drain field
(�No.
�rification Field 8 7 3 SQ ft *System Type: WFILTRATORQUICK4STANDARD
Drain Lines 4 Installer: Jamie Bames
Total Trench Length: a 1 8 ft. Certification#: 1018
Trench Spacing: _ 9 Inches O.C.
Feet O.C. *EHS: 2140-Nations,Robert
Trench Width: -- 3 Oinches
Date: 0 5 / 0 6 / 2 0 1 5
Aggregate Depth: inches
Minimum Trench Depth: 3 6
Inches
Minimum Soil Cover. 4Inches Approval Status°
Maximum Trench Depth: 3 6 Inches ®�Approved 0 -Disapproved
Maximum Soil Cover a 4
Inches
CDP File Number 193655 - 1 Septic Tank County ID Number: 5758884597 ,
Manufacturer. Shoaf Lat.
STB: 760 Long: ,
Gallons:
1000 Installer. Jamie Samos
Certification#: 1018
Date: 0 a / 1 8 / a 0 1 5 p
v r *EH S: 2140-Nat�,Robert
*Filter Brand: POLYLOK PL-122 With Pipe Adapter
ST Marker. E] Yes CD No
Date: 0 5 / 0 6 / 2 0 1 5
Approval status
Reinforced Tank: ❑ Yes ® No zxz
1 Piece Tank: ❑ Yes � No
--❑ Approved❑ Disapprovetl
z
Pump Tank
Manufacturer, Installer,
PT: Certification#:
Gallons: *EH S:
Date: / / Date. /
RiserSealed ❑ Yes ❑ No
RiserHeight: ❑ Yes ❑ NO (Min.6 in.) Approval Status
Reinforced Tank: ❑ Yes O No p Approved❑ Disapproved
1 Piece Tank: ❑ Yes ❑ NoV.
Supply Line
Pipe Size: inch diameter Installer
Pipe Length: feet Certification
*EH S:
#:
*Schedule:
Pressure Rated ❑ Yes ❑ No Date:
Approved fittings ❑ Yes ❑ No Approval Status
❑ Approved❑ Disapproved
Pump
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 Approvajstatus
PVC unions El Yes ❑ No ❑ Approved Disapproved
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole El Yes ❑ No
-CDP F1e Number 193655 - 1 County ID Number: 5758884597
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:
Alarm Audible E3 Yes El No
Appal,Status
❑ Approved❑ Disapproved
Alarm visible ❑ Yes ❑ No
2140-Nations,Robert
*Operation Permit completed by:
Authorized State Age Date of Issue. 5 / 0 6 / 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 TYPE 11 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 MspectioniMaintenance Frequency ByCertified Operator:
NIA
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 entitywith a certified operatoror a private certified operator forthe 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 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 for maintenance 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.
@Hand Drawing OlmportDrawing
**Site Plan/Drawing attached.**
OPERATION PERMIT 193655- 1
Davie County Health Department CDP File Number:
210 Hospital Street 5758884597
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: !
Q Inch
Drawing Drawing Type: Operation Permit Scale. QN A lock
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CONSTRUCTION For office Use Only
AUTHORIZATION F*CDPFt!eNum6er 193655= 1
Davie Count Health De artment 5758884597
Y p D Number.
210 Hospital Street Evaluated For: REPAIR.
P.O. Box'848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone: 336-753-6780 Fax:336-753-1680 0 5 / 0 6 / a 0 a 0
Applicant: Daniel York Pearl PropertyOwner. Daniel York Pearl
Address: 153 George Jones Road Address: 153 George Jones Road
City: Mocksville Cty: Mocksville
State/Zip: NC 27028 StatefLip: NC 27028
Phone#: Phone#:
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
885 Comatzer Road
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 64 East left on Cornatzer R. on the left corner of
#of Bedrooms: Comatzer and George Jones Rd
#of People:
'Water Supply: NIA
System Specifications
Minimum Trench Depth:
r
ssification: Provisionally Suitable a 4 Inches
Minimum Soil Cover.System? QYes (QNo 1ainches
low: 2 4 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-PARALLEL(eq.d-box)
TYPE Il A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
Septic Tank:
1 0 0 0 _ Gallons
`Proposed System: 25%REDUCTION 1-Piece: 0Yes QNo
Pump Required: oYes (J)No OMay Be Required
Nitrification Field 8 7 3 Sq.ft. Pump Tank: Gallons
No.Drain Lines 4 1-Piece: QYes QNo
Total Trench Length: a 1 8 ft GPM vs— ft. TDH
Trench Spacing: Inches O.C.
9 . @Feet O.C. Dosing Volume: _ Gallons
Trench Width:
W — 3 - 2inches
Feet Grease Trap: Gallons
Aggregate Depth: inches Pre-Treatment: ONSF OTS-) OTS-II
Septic Tank Installer Grade Level Required: 01 011 0111 oiv
Pflno � nf'�
CDP Fite Number 193.655 - 1 County ID Number. 5758884597
❑ Open Pump System Sheet
Repair System Required:OYes ONo @No, but has Available Space
rnesign
System
Trench Spacing: Q Inches O.
ification: — Q Feet O.C.
Trench Width: 0Inches
w: — Feet
Soil Application Rate: Aggregate Depth: inches
Minimum Trench Depth:
*System Classification/Description: Inches
Minimum Soil Cover. Inches
Maximum Trench Depth:
*Proposed System: Inches
Maximum Soil Cover
Nitrification Field Inches
Sq.ft.
No. Drain Lines
*Distribution Type:
Total Trench Length; . Pump Required: Oyes, ONo OMay Be Required
Pre-Treatment: ONSF OTS-1 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 forWastewater system Construction shall bevaltd fora person equal to the period of validity ofthe Improvement Perms;not
to exceed five years,and may be issued at the sane the Improvement Permit Issued(NCGS 130A-=(b)j If the installation has not been
completed during the period of valldity ofthe Construction Permit,the information submitted in theapplicallon for a permit or Construction
Authorization is found to have been incorrect,falsified or changed,or the site Is altered,the permK or Construction Authorization shall become
Invalid,and may be suspended or revoked(.1937(g)).The person owning or,controlling the system shall be responsible forassuring 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 5 / 0 6 / 2 0 1 5
Authorized State Age ` �� Malfunction Log OYesg.;
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital street CDP File Number: 193655- 1
P.O.Box 848 5758884597
Mocksville NC 27028 County File Number:
Date: .0 .5 / 0 6 / 2015
Glick below to Import an Image from an external location: Drawing Type:Construction Authorization
CONSTRUCTION AUTHORIZATION
Davie County Health Department CDP FileNumber. 193656-
210
93655-210 Hospital Street 5758884597
P.O.Box Bas County File Number:
Mocksville NC 27028 Date: 0 5 / 0 6 / 2 0 1 5
Q Inch
Drawing Drawing Type: .Construction Authorization Scale: . . QBlock
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