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1478 Country Home Rd OPERATION PERMIT For Office use CHIy- Davie County Health Department *CDP File Number 121743- 1 210 Hospital Street J3-000-00-052 P.O. Box 848 County ID Number. Mocksville NC 27028 Evaluated For: NEW Phone: 336-753-6780 Fax:336-753-1680 Township: FAd ant: Farren Shoaf r operty Owner: Ruth Collette ss: 431 Eaton Road ddress: 1478 County Home Rd Mocksville RY: Mocksville State/Lip: NC 27028 StatefZip: NC 27028 Phone#: (336)751-9375 Phone#: Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: 1478 Country Home Rd Mocksville NC 27028 Directions Structure: SINGLE FAMILY Pass Ingersoll Rand, pass Detention Center property #of Bedrooms: 2 on right #of People: 2 *Water Supply: NEW WELL *IP Issued by. *System Classification/Description: TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140-Nations,Robert SaproliteSystem? ®Yes QNo Design Flow: a 4 0 *Distribution Type: GRAVITY-PARALLEL(eq.d-box) Pump Required? OYes ONo Soil Application Rate: 0 - 2 *Pre Treatment: Drain field Nitrification Field 1 a 0 0 S4•ft. *System Type: INFILTRATOR QUICK STANDARD No. Drain Lines 3 Installer: Tommy Frye Total Trench Length: 3 0 0 tt• Certification#: 1069 Trench Spacing: _ 9Inches O.C. Feet O.C. EH S: 2140-Nations,Robert Trench Width: _ 3 Olnches Q Feet Date: 1 0 / 0 9 / .2 0 1 4 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. 3 a Inches Approval Status _ Maximum Trench Depth: 3 6 Inches FEI proved O Disapproved Maximum Soil Cover: a 4 Inches CDP File Number 121743 - 1 Septic Tank County ID Number: J3-000-00-052 r nufacturer. taylorsville precast Lat. STB: 760 Long: Gallons: 1000 Installer: Tommy Frye Certification#: 1069 Date: 0 6 / a l / a 0 1 4 *EHS: 2140-Nations,Robert *Filter Brand: ST Marker. El Yes El NO Date: 1 0 / 0 9 / 2 0 1 4 Reinforced Tank: ❑ Yes El No Approval Status , Piece Tank: ❑ Yes O No 0 Approved❑ Disapproved Pump Tank Manufacturer. Installer: PT: Certification#: Gallons: *EHS: Date: / / Date: Riser Sealed ❑ Yes ❑ No Riser Height: ❑ Yes ❑ NO (Min.6 in.) Approval Status einforced Tank: 13 Yes ❑ No 11Approved❑ Disapproved 1 Piece Tank: ❑ Yes ❑ NO Supply Line Pipe Size: inch diameter Installer. Pipe Length: feet Certification#: *EHS: *Schedule: Pressure Rated ❑ YeS ❑ NO Date: Approved fittings ❑ Yes ❑ No Approval Status ❑ Approved❑ Disapproved Pump e 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 Approval Status PVC unions ❑ Yes ❑ No ❑ Approved❑ Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole 0 Yes 0 No CDP File Number 121743 - 1 County ID Number. J3-000-00-052 Electric Equipment NEMA 4X Box or Equivalent El Yes El 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: Approval Status Alarm Audible El Yes ElNo ❑ Approved❑ Disapproved Alarm Visible El Yes ❑ NO 2140-Nations,Robert *Operation Permit completed by: Authorized State Agent: Date of Issue: 1 0 1 0 9 1 a 0 1 4 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: N/A Management Entity: OWNER Minimum System Inspection/Maintenance Frequency By Certified Operator: N/A Reporting Frequency By Certified Operator. N/A 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 entitywith a certified operator forthe 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 entity, unless the system owner and 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. OHand Drawing Olmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT 121743 - 1 Davie County Health Department CDP File Number: 210 Hospital Street County File Number: J3-000-00-052P.o.Box$48 Mocksville NC 27028 Date: / Olnch Drawing Drawing Type: Operation Permit ale: OBlock ON/A LF LJ--- - t -i Ij ( I I_ ___ LTI I I I I I � I L_ � I� I� t I I i_ ► ! ��- I _l-__ I I j_ EI i C,_ ! � t i ►- _� I I _ I I I I I ►_ _,_ _ I I _i_�__11 ill CONSTRUCTION For office Use Only AUTHORIZATION *CDP Flle Number 121743 1 obi�- Davie Count Health De artment I. 000 00 052 Y P CountID Number 210 Hospital StreetEvaluated For P.O. Box 848 Township: Mocksville INC 27028 PERMIT VALID UNTIL: Phone:336-753-6780 Fax:336-753-1680 0 5- / 1 9 .1 0 1 9 Applicant: Farren Shoaf Property Owner: Ruth Collette Address: 431 Eaton Road Address: 1478 County Home Rd City: Mocksville City: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 Phone#: �116'751-9375 Phone#: Property Location &Site Information rAddress/Road,#: Subdivision: Phase: Lot: CountHome Rd ksville NC 27028 Directions Structure: SINGLE FAMILY Pass Ingersoll Rand, pass Detention Center property on right #of Bedrooms: 2 #of People: 2 *Water Supply: NEW WELL System Specifications Minimum Trench Depth: a 4 rDesign ssification: Provisionally suitable Inches System? Minimum Soil Cover. 1 a y i&Yes ONo Inches low: • ct 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 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 0GPM—vs— ft. TDH ft. Trench Spacing: _ O g Inches O.C. ®Feet O.C. Dosing Volume: Gallons Trench Width: _ 3 OInches ADepth: ®Feet Grease Trap: Gallons Aggregate inches Pre-Treatment: O NSF OTS-I OTS-II Septic Tank Installer Grade Level Required: 01011 0111 O N Page 1 of 3 CDP File Number 121743 1 County ID Number: J3-000-00-052 ❑ Open Pump System Sheet Repair System Required:0 Yes O No O No, but has Available Space CDesign ystem Inches O.C. Trench Spacing: 9 O fication: Provisionally Suitable — ®Feet O.C. Trench Width: O Inches : .2 4 0 _ 3 ®Feet Aggregate Depth: inches Soil Application Rate: 0 a .� *System Classification/Description: Minimum Trench Depth: a 4 Inches LESS)TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Minimum Soil Cover: 1 Inches *Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Nitrification Field 1 -2 0 0 Sq.ft. Maximum Soil Cover: a 4 Inches No. Drain Lines 3 *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 aca 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. Rmaining 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? Oyes ONO Applicant/Legal Reps.Signature* Date: *Issued By: 2140-Nations,Robe Date of Issue: 5 / 1 9 / 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 Davie County Health Department CDP File Number: 121743 - 1 210 Hospital Street J8-000-00-052 P.O.Box 848 County File Number: Mocksville NC 27028 Date: 0 5 / 1 9 / 20 1 4 0Inch Drawin;? Drawing Type: Construction Authorization Scale: 00 Neck b 0�111.116, 91i� li(/ aws 1D lj I UA.r d Page 3 of 3 P1 P2 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital street CDP File Number: 121743 - 1 P.O.Box 848 J3-000-00-052 Mocksville NC 27028 County File Number: Date: .0.5./.1.9. /..2 0 1.4. Click below to import an image from an external location: Drawing Type: Construction Authorization Page 3 of 3 P1 P2 IMPROVEMENT PERMIT Forofficeuse only • �~ *CDP Fite Number 121743-1 �•'u't- Davie County Health Department County ID Number.J13-000-00-052 f- 210 Hospital Street P.O. Box 848 Evaluated For: NEW Mocksville NC 27028 Township: Phone:336-753-6780 Fax:336-753-1680 PER ALID UNTIL' 18 *NOTE TO INSPECTION S,DIVISION:..Building Permits cannot be issued this Improvement Permit. Applicant: Farren Shoaf 7Prope owner. Ruth Collette Add ss: 1478 County Home Rd Address: 431 Eaton.Road City: Mocksville City: Mocksville State2ip: NC 27028 State NC 2702$ Phone#: (336)751-9375 Phone#: Propea Location & Site Information Sdress/Road#: Subdivision: Phase: Lot: 478 Country Home Rd 0 27028 Directions Structure: SINGLE FAMILY Pass Ingersoll Rand, pass Detention Center property #of Bedrooms: 2 on right #of People: 'Water Supply: NEW WELL System Specifications nitial System *Site Classification: Ps Minimum Trench Depth: 2 4 Inches Saprolite System? QYes ONo Maximum Trench Depth: 3 6 Inches Design Flow: 2 4 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 0 2 1-Piece: OYes GNo Pump Required: OYes G No O May Be Required 'System Classification/Description: TYPE Il A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons LESS) 'Proposed System: 25%REDUCTION 1-Piece: OYes ONo Repair System Required:G Yes ONO ONO, but has Available Space Repair System CssoitilApplication e Classification: PS Minimum Trench Depth: 2 4 Inches Rate: 0 - 2 Maximum Trench Depth: 3 6 Inches *System Classification/Description: Pump Required: OYes G No O Maybe Required TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System: 25%REDUCTION Page 1 of 3 - CDP File Number 121743- 1J"00-00-052 County ID Number. *Site Modifications ❑ 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 bythe Health Department in nowayguarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. Site Plan The Improvement Pnu elt shall be valid for 8 years from date of Issue with a site plan(means a drawing not necessarily dfawn 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 surveyor,drawn to a scale of one Inch equals no more than 60 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 Departrrrent may Impose conditions on the Iswanceand 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 pan,plat,or intended use changes(NCGS 130A335(q).The person owning or controlling the system shall be msponslble for assuring compliance with the laws,sties,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,Andrew Date of Issue: 0 6 / 1 9 / 2 0 1 3 OValid without Expiration? Authorized state Agent:rj'&"AAU� OCreate CA. 01-land Drawing Olmport Drawing **Site Plan/Drawing attached.** TotalTime:(HH: 1M) 0 1 Hours 0 0 ulnutes Page 2 of 3 Activity Code: S-4-IP'S issued:new,valid for 60 mos. IMPROVEMENT PERMIT Davie County Health Department CDP File Number: 121743 - 1 210 Hospital Street P.O.Box 848 County File Number. J3-000-OD-052 Mocksville NC 27028 Date: Q Inch Drawing Drawing Type: Improvement Permit Scale: . OBlock , QN/A—ILL -S.0-4 J -46 - __ 6P10 S imK- I �__-} i I 17- - ; -L L -------- -1-77 1 1 lam!_I (� Page 3 of 3 APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O.Bog 848/210 Hospital Street Mocksville,NC 27028 p (336)753-6780/Fax(336) 53-1680 ' -2' 7�,�I--1` ,��a !y 3 Application For: GYSite Evaluation/ImprovemenTPermit 4V Autho tion To Construct(A Both Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing Syste acility ***IMPORTANT"**THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULT.ETIN for instructions. APPTJC'ANT INFORMATION Name &,<`!e-J �� Contact Person l-y -V-) Address _ 3 lr2ef Home Phone '7D V !!:EO�)- -15- y City/State/ZIP o C S v i Business Phone Email b►..� l.va, 0^^ Name on Permit/ATC ifDfferent than Ab-dye Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged 6-1 NOTE: A survey plat or site plan must accompany this application. Included: Site Plan ❑Plat(to scale) (Permit is val' for months with i p no expiration with complete plat.) Owner's Name' " U � el Phone Number Owner's Address t/ 7 ti� ! City/State/Zip 0A.� Property Address CityM be k.S ui Lot.Size C-TA-'> Tax PIN# 3^QOQ_j�0"bfiZ Subdivision Name(if applicable) -Section/Lot# Directions To Site: e r5o1 0 LK^ o^t 12 J 54 v. e 6 t <-V If the answer.to any of the following qdestions is"Yes",supporting doc ntation must be attached: Are there any existing wastewater systems on the site? Yes o Does the site contain jurisdictional wetlands? Yes / lo Are there any easements or right-of-ways on the site? Yes N Is the site-subject to approval by another public agency? _Yes ' Will wastewater other than domestic sewage be generated? Yes o TF RESIDENCE FTT T,01 JT TRE BOX BELOW #People #Bedrooms #Bathrooms Garden Tub/Whirlpool ❑Yes EIo Basement: Yes o Basement Plumbing: ❑Yes Pf4o .TF NON-RESIDENCE.FIT,L,OUT THE BOX.BFMOW . 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: Gd'Conventional ❑Accepted ❑Innovative ❑Altemative ❑Other Water Supply Type: ❑ County/City.Water Bt/New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? IT Yes Wf o 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 corners and locating and flagging or staking a house/facity locatio ,pr osed well location and the location of any other amenities. Property owner's or owner's leg rept entative signature Site Revisit Charge Date(s):-,:;6) 3 Client Notification Date: Date EHS: Sign given ❑Yes ❑No n / G 6' � Account# Revised 11/06 Invoice# �C.z v- yo J� kk°V '! -' , • '• ' DAVIE COUNTY HEALTH DEPARTMENT Environmental �ealth Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION F rrery SA4 l / Water Supply: On-Site Well ­4 Community Public y Evaluatioh By: Auger Boring 5 Pit FACTORS 1 2 3 0 6 0 7 Landscape position [, L Slope% e HORIZON I DEPTH p .. Texture group GG C SO Consistence Structure Mineralogy HORIZON H DEPTH ,;Zy f Texture group C Consistence S tructure Mineralogy HORIZON III DEPTH %0 _ Texture group Consistence Structure t . Mineralogy HORIZON IV DEPTH ;. -Texture group - ..> Consistence - , < • .. u. Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE .,2 SITE CLASSIFICATION: �S EVALUATION BY: 14rLdKO AQ LONG-TERM ACCEPTANCE RATE: i`?_ 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 CONSIST +.N .E Moos ' VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm 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 lY4teS . 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) T TAR -i nno_trrm Aeri-ntanrr+rate aal/baa/ftp r�nrrr%nc,nc /in ■.se■/.■■■■www■■■■w■■■■■w■■■ww■w'�■■i■■■ww■■■■■■www■■w■■■■■w■w.w■s■ ■■.ori■■■■■■■■■■■■■■/■■■■■■■�■.■■■sc�■■■■■■■■■■■■■■■■■■■■■■■■■■.■■.■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■IC.... 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