1684 Davie Academy Rd UnFv
OPERATION PERMIT EEvaluated
ice use
Davie County Health Department Number 121749-1
r Q 210 Hospital Street
P.O. Box 848 umber:.
°- Mocksville . NC 27028 r: REPAIR
Phone:336-753-6780 Fax:336-753-1680
Applicant: Jerry Seamon Property owner: Jerry Seamon
Address: 1684 Davie Academy Rd. Address: .292 Shady Knoll Ln
City: Mocksville City: Mocksville
State2ip: NC 27028 State2ip: NC 27028
Phone#: Phone#:
Property Location & Site Information
rAddre
sslRo
ad #: Subdivisan: Phase: Lot:
1684 Davie Academy Rd
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 64 west to Davie Academy
#of Bedrooms: 3
#of People:
*Water Supply: NIA
*IP Issued by. 22x4-Daywalt,Andrew 'System Classification/Description:
TYPE II A CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
'CA issued by: 2244-Daywalt,Andrew
SaproliteSystem? OYes QNo
Design Flow:
2 4 0 `Distribution Type: GRAVITY-SERIAL Pump Required?
OYes (DNo
Soil Application Rate: 0 3 *Pre Treatment: NIA
Drain field
(L
Nitrification Field Sq.ft. *System Type: INFILTRATOR QUICK 4 STANDARD
No. Drain Lines Installer. randy miller and son
Total Trench Length: 2 0 0 ft Certification#:
Trench Spacing: _ Oinches O.C.
Feet O.C. ENS: 2244-Daywalt,Andrew
Trench Width: Inches
— Feet Date: 0 5 / 2 9 / 2 0 1 3
Aggregate Depth: inches
Minimum Trench Depth: Inches
Minimum Soil Cover. Inches Approval Status
Maximum Trench Depth: Inches FaEl proved D Disapproved
Maximum Soil Cover:
Inches
Ullti3
CDP File Number 121749 - 1 County ID Number:
Septic Tank
Manufacturer. existing Lat. -
Long: -
STB:
Gallons: Installer.
Date: / / Certification#:
'EHS: 2244-Daywalt,Andrew
'Filter Brand:
ST Marker: ❑ Yes ❑ No Date:
7;;
d Tank: ❑ Yes ❑ NOApproval Status
e Tank: ❑ Yes ❑ No E, Approved❑ Disapproved
Pump Tank
Manufacturer. Installer:
PT: Certification#:
Gallons: 'EHS:
Date: / / Date:
RiserSealed ❑ Yes ❑ No
RiserHeght: ❑ Yes ❑ No (Min.6 in.)
Approval Status
einforced Tank: ElYes ❑ No ElApproved❑ Disapproved
1 Piece Tank: ❑ Yes ❑ No
Supply Line
Pipe Size: inch diameter Installer:
Pipe Length: feet Certification#:
'Schedule: 'EHS:
Pressure Rated ❑ Yes ❑ No Date: /
Approved fittings ❑ Yes ❑ No Approval Status
❑ Approved❑ Disapproved
Pump RgqU1rgmgnt
(' 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 121749 - 1 County ID Number:
Electric Equipment
NEMA 4X Box or Equivalent El Yes ❑ No Installer:
Box 12 inches Above Grade ❑ Yes ❑ NO
Certification#:
Box Adj.To Pump Tank ❑ Yes ❑ N0
Conduit Sealed ❑ Yes ❑ NO 'EHS:
Pump Manually Operable ❑ Yes ❑ NO
*Activation Method: Date:
Approval Status
Alarm Audible ❑ Yes ❑ No ❑ Approved❑ Disapproved
Alarm visible El Yes ElNo
2244-Daywalt,Andrew
*Operation Permit completed by:
Authorized State Agent: Date of Issue: 0 5 / 2 9 / 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 11 A sewage septic system.
Rule.1961 requires that a Type TYPE 11 A. septic system meet the following criteria:
Minimum System Review By The Local Health Department: N/A
Management Entity: OWNER
Minimum System InspectionlMaintenance Frequency By Certified 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 operator or 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 priorto the
issuance of an Operation Permit for a system required to be maintained bya 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.
. Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Total Time:(HH:MI.i)
Activity Code: S-19 204-OP issued NEW Type 11 Ouick 4 0 1 Hours 0 0 minutes
` OPERATION PERMIT
Davie county Health Department CDP File Number: 121749 - 1
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date:
Qlnch
Drawing Drawing Type: Operation Permit Scale: , QBlock ft.
QN/A
J1X , ,
Ylu
T— 4Z
A
1-sem!►._ _ate� - ��_-� ��i- -� -� � ___ .._ ;
I
FFI
► i
_------
CONSTRUCTION For Office use Only
AUTHORIZATION *CDP File Number 121749-1
= Davie County Health Department County ID Number:
t 210 Hospital Street Evaluated For: REPAIR
P.O.Box 848
•o:-•..• Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 0 1 / 0 1 0 0 0 6
Applicant: Jerry Seamon Property Owner. Jerry Seamon
Address: 1684 Davie Academy Rd. Address: 292 Shady Knoll Ln
CRY: Mocksville City: Mocksville
State2ip: NC 27028 State2ip: NC 27028
Phone#: Phone#:
Property Location & Site Information
rAddress/Road ;g: Subdivision: Phase: Lot:
84 Davie Academy Rd
cksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 64 west to Davie Academy
#of Bedrooms: 3
#of People:
*Water Supply: NiA
System Specifications
Minimum Trench Depth: 2 4
rSitessification: PS InchesMinimum Soil Cover.System? OYes QNo Inchesesgnlow: 2 4 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: Maximum Soil Cover:
0 3 Inches
*System Classification/Description: *Distribution Type: GRAVITY-SERIAL
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
Gallons
*Proposed System: 25%REDUCTION 1-Piece: OYes Q N o
Pump Required: OYes QNo OMay Be Required
Nitrification Field
Sq.ft. Pump Tank: Gallons
No.Drain Lines 1-Piece`. OYes ONo
Total Trench Length: 2 0 0 ft GPM—vs— ft. TDH
Trench Spacing: _ QInches O.C. Dosing Volume: _ Gallons ,
- 8Feet O.C.
Trench Width: Inches
_ 8Feet Grease Trap: Gallons
Aggregate Depth: inches
Pre Treatment: ONSF OTS-I OTS-II
Septic Tank Installer Grade Level Required: OI Oil OIII OIV
Pagel of 3
CDPfile Number 121749 - 1 County ID Number.
❑ Open Pump System Sheet
Repair System Required:OYes ONo ONo, but has Available Space
rDesign
System
Trench Spacing: Inches O. .
ification: — 8 Feet O.C.
15A NCAC 1 *'"`�'"""` 8Fe tes
w:
Soil Application Rate: Aggregate Depth: inches
Minimum Trench Depth:
'System Classification/Descr9�e pair Area Exe ►I � Inches
Inches
Maximum Trench Depth:
'Proposed System: Inches
Maximum Soil Cover.
Nitrification Field Inches
Sq.ft.
No. Drain Lines 'Distribution Type:
Total Trench Length: ft Pump Required: QYes 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 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 atthe 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 sub mated 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? Oyes ONo
Applicant/Legal Reps.Signature- Date:
'Issued By: 2244-Daywalt.Andrew Date of Issue: . 0 5 / 2 9 / 2 0 1 3
Authorized State Agent: Malfunction Log OYes
OHand Drawing Olmport Drawing Total Time:("KMM)
**Site Plan/Drawing attached.**
Page 2 of 3 0 1 Hours 3 0 u lnutes
S-10-CNS issued-repair
• CONSTRUCTION AUTHORIZATION 121749 - 1
` Davie County Health Department CDP File Number:
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 0 5 / 2 9 / 2 0 1 3
O inch
Drawing Drawing Type: Construction Authorization Scale: , OBlock ft.
ON/A
eX`
-_ -- --- ►---I _ ---- '� E -� --- -_ L-L.
wol1
Pane 3 of 3