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431 Deadmon Rd OPERATION PERMIT ice se ny , Davie County Health Department *CDP File Number 139308-1 f- 210 Hospital Street P.O. Box 848 County ID Number: Mocksville NC 27028 Evaluated For: REPAIRi Phone:336-753-6780 Fax:336-753-1680 Township: Applicant: Carol Allen Property Owner: Carol Allen Address: PO Box 672 Address: PO Box 672 City: Mocksville City: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 Phone#: (704)640-9770 Phone#: (704)640-9770 Propeft Location & Site Information Address/Road#: Subdivision: Phase: Lot: 431 Deadmon Road Mocksville NC 27028 Directions Structure: MOBILE HOME Hwy 601 South, left on Deadmon, on left past #of Bedrooms: 3 Goldman Rd on right #of People: *Water Supply: PUBLIC *IP Issued by: *System Classification/Description: TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140-Nations,Robert Saprolite System? O Yes 9 No Design Faow: 3 6 0 *Distribution Type: GRAVITY-PARALLEL(eq.d-box) Pump Required? O Yes RNo Soil Application Rate: 0 a 7 5 *Pre-Treatment: Drain field Nitrification Field 1 3 0 9 Sq.ft. *System Type: INFILTRATOR QUICK 4 STANDARD No. Drain Lines Installer: Sherman Dunn Total Trench Length: 3 a 7 ft. Certification#: Trench Spacing: _ 9 0Inches O.C. 0 Feet O.C. EHS: 2140-Nations,Robert Trench Width: _ 3 Olnches ®Feet Date: 0 7 / 0 a / a 0 1 4 Aggregate Depth: inches Minimum Trench Depth: Inches Minimum Soil Cover: Inches Approvkal Status 3 3 Maximum Trench Depth: ® ApprOVed❑'4Dlsapproved nc Maximum Soil Cover: Inches Page 1 of 4 CDP File Number 139308- 1 Septic Tank County ID Number: Manufacturer: Lat. STB: Long: Gallons: Installer: Date: / / Certification#: *EHS: *Filter Brand: ST Marker: ❑ Yes ❑ No Date: Approval Stat�is�"�� �'�a y' Reinforced Tank: ❑ Yes ❑ NO ❑ Rppra�red❑ Dlsa rave ,; 1 Piece Tank: El Yes El No Pump Tank Manufacturer: Installer: PT: Certification#: Gallons: *EHS: Date: / / Date: Riser Sealed ❑ Yes ❑ No Riser Height: ❑ Yes ❑ No (Min.6 in.) 3 Approval Statusy3 Reinforced Tank: El Yes El No "," CD Approved❑ Dlsappr� ed 3 3 3 K1 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 � � �r333���ApprovalStatrfs ❑ Approved❑ Dlsapp ped F ,! � . Pump Requorement Pump Type: Installer: Dosing Volume: - Gal Certification#: Draw Down: Inches *EHS: *Chain: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No O Check-valve ElYes ElNO �' ' App�roai Sty{s r�3y1 „ � t PVC Unions ❑ Yes ❑ No ( 3Appro ❑ isapprovec Vent Hole ❑ Yes ❑ NO Anti-siphon Hole ❑ Yes ❑ No Page 2 of 4 CDP File Number 139308- 1 County ID Number: Electric Equipment NEMA 4X Box or Equivalent ❑ Yes ❑ 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. ❑ Arovrova!Status Alarm Audible El Yes NO Alarm Visible El Yes 1:1 No pp ed❑ ©lSapproved z,� , 2140-Nations,Robert *Operation Permit completed by: Authorized State Agent: T Date of Issue: 0 / 0 a l 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.1 900 et Seq.,and all conditions of the Improvement Permit and Construction Authorization.This property is served by a TYPE Ii A. sewage septic system. Rule.1961 requires that a Type TYPE II A. septic system meet the following criteria: Minimum System Review By The 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 for a home/business owner must maintain a valid contract with a public management entity with a certified operator or a private certified operator for the life of the septic system. 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 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 O Import Drawing **Site Plan/Drawing attached.** Page 3 of 4 .. r CONSTRUCTION For office use Only, AUTHORIZATION *CDP File Number 139308-1 •"- Davie County Health Department County ID 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 6 / a 4 a 0 1 9 Applicant: Carol Allen Property Owner: Carol Allen Address: PO Box 672 Address: PO Box 672 City: Mocksville 7 City: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 �,_Pho�ne#. �704,�640-97�70 Phone#: (704)640-9770 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: 431 Deadmon Road Mocksville NC 27028 Directions Structure: MOBILE HOME Hwy 601 South, left on Deadmon, on left past Goldman Rd on right #of Bedrooms: 3 #of People: *Water Supply: PUBLIC System Specifications Minimum Trench Depth: a 4 rDesign fication: Provisionally suitable Inches System? Minimum Soil Cover: 1 a OYes 4KNo Inches : 3 6 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 II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: Gallons *Proposed System: 25%REDUCTION 1-Piece: OYes ®No Pump Required: OYes ONo ®May Be Required Nitrification Field 1 3 0 9 Sq.ft. Pump Tank: 1 0 0 0 Gallons No. Drain Lines 3 1-Piece: OYes (&No Total Trench Length: 3 a 7 ft GPM—vs— ft. TDH Trench Spacing: - 9 o FOInches O.C. eet O.C. Dosing Volume: Gallons Trench Width: 3 Inches Feet Grease Trap: Gallons Aggregate Depth: inches Pre-Treatment: O NSF OTS-1 OTS-II Septic Tank Installer Grade Level Required: 01011 O III ON Page 1 of 3 CDP File Number 139308 - 1 County ID Number: ❑ Open Pump System Sheet Repair System Required:0 Yes O No O No, but has Available Space rDesignFlow: System Trench Spacing: O Inches O.C. fication: — O Feet O.C. Trench Width: Inches _ Feet Soil Application Rate: Aggregate Depth: inches .� *System Classification/Description: Minimum Trench Depth: 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: ft Pump Required: OYes 0N OMay Be Required Pre-Treatment: O NSF OTS-1 OTS-II *Site Modifications actm 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. R If the entre repair can not be placed to the side of the home facing to the right and meet setbacks,a pump tank must be added to the septic tank and 1807 pump to a higher elevation on the property. 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 130A336(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(9)).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: 2140-Nations,Robert Date of Issue: 0 6 a 4 a 0 1 4 Authorized State Agent: Malfunction Log Oyes (9 Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION 139308- 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: 06 / a4 / ,2014 O Inch Drawing Drawing Type: Construction Authorization Scale: . O Block O N/A �SA X, S o in I 7Z rt Page 3 of 3 P1 P2 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: 139308 - 1 P.O.Box 848 Mocksville NC 27028 County File Number: Date: .0.6./ a 4 / a 0 14 Click below to import an image from an external location: Drawing Type: Construction Authorization Page 3 of 3 P1 P2 Davie COUNTY 210 Hospital Street P.O. Box 848 Mocksville NC 27028 TEL: 336-753-6780 FAx: 336-753-1680 Request ID: 49280 REQUEST FOR SERVICE/COMPLAINT INVESTIGATION REPORT REQUEST DATE: 06/24/2014 TAKEN BY: SECTION: N/A TYPE: PROPERTY NUMBER: 139308 ASSIGNED TO: Nations, Robert ESTABLISHMENT NUMBER: PERSON OR PREMISES TO SEE: OWNER: Carol Allen Carol Allen PO Box 672 431 Deadmon Road Mocksville , 27028 Mocksville NC, 27028 (704) 640-9770 REQUESTED BY: Owner HOME: WORK: Cell: CONDITION REPORTED:septic tank old,backing up, pumped today COMMENTS: RECORD OF INVESTIGATION DATE: HR/MT: COMMENTS EHS: EHS #: ACT CODE: DATE: HR/MT: COMMENTS EHS: EHS #: ACT CODE: DATE: HR/MT: COMMENTS EHS: EHS #: ACT CODE: DATE: HR/MT: COMMENTS EHS: EHS #: ACT CODE: DATE: HR/MT: COMMENTS EHS: EHS #: ACT CODE: Next Inspection Date: Status of Complaint: OPEN Resolved Date: Complaintant Contacted: NO DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUESTiw) �7 `�/ APPLICATION IP/ATC OSWW REPAIR /?Oq 6L�019 / 10 Name �l`�./W( U" telephone Number /K &-60 Address Mailing Address (if different from above) Email Address: Subdivision Name Lot# Directions Date System Installed Name System Installed Under Type Facility Number Bedrooms 3 Number People Served Type Water S pply Specific Problem Occurring� Pi Date Requested (p-�!/— Info Taken By V THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY KNOWLEDGE,AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED FROM THIS APPLICATION. Signature of owner or Authorized Agent Initial Fee Date REHS Revisit Charge Date Reason Revised 2-2011 tVI10, Y'&7 v I l/WS✓�/�. "V V (Y '; \ r- �� l D�i"d'It ZOUNTY ENVIRONMENTAL HEALTH SERVICE RE UES { APPLICATION IP/ATC OSWW REPAIR. 70 60-91710 \` Name ���� A ' Telephone Number /�7 �Y 30-V 9�r Address 1 Z)Odlkloa 6 0 4.51 06 1C Mailing}Address (if different from above) Email Address: Subdivision Name �j>,` ! Lot# Directions 1 Date System Installed Name System Installed Under Type Facility Number Bedrooms -� Number People Served Type Water S pply Specific Problem Occurring (« Date Requested Info Taken By e4 THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY KNOWLEDGE,AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED FROM THIS APPLICATION. -Signature of owner or Authorized Agent Initial Fee Date REHS , - Revisit Charge F Date Reason �� Revised 2-2011 — # Page 1 of 1 �,,,• �VW�uuVVu �,uma�aw�Wr .�V Report $lel rch Tools Property Card' FmdAdjoiners f Select map: Panels Parcelhum6er. K500000020 P H Rumben 574742E957 Active Layer, Parcels AccountNuni6ert 542090 ParCO-k KapT4►s 'Usted owner fl: ALLEN CAROL Z Maptaysrs 5earchToois Map ToolslistedDwner#2: Mating Address is PO EOX 672 [wick Report Results legend Mang Address 2: ;i" 49W 140MVILLE Davie[oontyRome j 004ma RC hF 474 Zip Code: 27428-4672 4 kA�, Legal Description: 1.6 AC DFS MON RD :3 413 ''Atreage: L69 f 373 '426 '74G- 359 & , 374 73 7 m't f 4l — a 4CQ 4 r 1 129 .328Y 715 �n 711 ` f 14 _ e �` X137 131 ` & 123111 164 V Y Q. lfia n�s 571 p187_ 540 ft Lak;vde:35r 51' 52,25' longi, de:-$p°32 1 .37" m http://maps2.roktech.net/davie�__gomaps/l*ndex.html 6/24/2014