219 Dorse Rd 1
OPERATION PERMIT FEvaluatedfor
ice Use Only
Davie County Health Department Number 191976-1-
210 Hospital Street
P.O. Box 848 umber.
Mocksville NC 27028 NEWPhone:336-753-6780 Fax:336-753-1680
Applicant: America's Home Place Inc Property Owner. Caleb Garret Davis
Address: 1206 Green Lane Drive Address:
City: Statesville City:
StatefLip: NC 28677 StatefZip:
Phone#: (704)746-7094 Phone#: �(33�6)978�-6192
Property Location & Site Information
Address/Road #: Subdivision: Phase: Lot:
,r (� Dorse Road
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY 1-40 West exit 162 turn right onto US -64 EAST 2.7
MILES TURN RIGHT ONTO DAVIE ACADAMEY
of Bedrooms: 3 TURN RIGHT ON STAGECOACH RD. TURN RIGHT
9 of People: ON DORSE ROAD LOT ON LEFT
*Water Supply: NEW WELL
*IP Issued by. 2140-Nations,Robert *System Classification/Description:
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by: 2140.Nations,Robert SaprotiteSystem? QYes QNa
Design Flow: 3 6 0 'DistIributionType: GRAVITY-SERIAL Pump Required?
QYes QNo
Soil Application Rate: 0 - a 5 *Pre Treatment:
Drain field
14 deification Field 1 4 4 0 Sq.ft• *System Type: INFILTRATOR QUICK 4 STANDARD
No. Orcin Lines 4 Installer: Tim Gunter
Total Trench Length: 3 6 0 It. Certification#: 1082
Trench Spacing: — 9 Inches O.C.
()Inches
O.C. *EH S: 2140-Nations,Robert
Trench Width: ()Inches3
Feet Date: 0 5 / a 9 / a 0 1 5
Aggregate Depth: inches
Minimum Trench Depth: 3 6
Inches
77
Minimum Soil Cover. a 4 Approyat Status
Inches "
1Maximum Trench Depth: 3 6 Inches Ei :Approved O Disapproved=
111JMaximum Soil Cover: 2 4 Inches
CDP File Number 191976 - 1 Septic Tank County ID Number:
Manufacturer. shoal Let.
,
STB: 760 Long:
Gallons:
1000 Installer. rim Gunter
Certification#: 1082
Date: 0 2 / 1 8 / 2 0 1 5
*EHS:
*Filter Brand: POLYLOK PL-122 With Pipe Adapter
ST Marker Date: 0 5 / a 9 / a 0 1 5
• ❑ Yes ❑ No
Reinforced Tank: ❑ Yes No
= Approval Status
1 Piece Tank: ❑ Yes ® NO
(� Approved❑ Disapproved
Pump Tank
Manufacturer. Installer,
PT: Certification#:
Gallons: *EH S:
Date: / / Date:
RiserSealed ❑ Yes ❑ No
RiserNeight: El Yes
El N4 (Min.6 in.)
Approval Status
ReinforcedTank: ❑ Yes ❑ Na ❑ Approved❑ Disapproved
1 Piece Tank: ❑ Yes ❑_ NO e
Supply Line
FPipoeize: inchdiameter Installer
gth: feet Certification#:
Schedule: *EHS:
Pressure Rated ❑ Yes ❑ No Date: /
Approved fittings ❑ Yes ❑ No Approval status
❑ Approve d❑ DisapproveAo
Purnp Requirement
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 AIS
pprovatatus,
PVC unions ❑ Yes ❑ No ❑.'Approvetl� Disapproved ,
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole ❑ Yes ❑ No
-CDP File Number 191976 - 1 County ID Number:
Electric Equipment
NEMA4XBoxorEquivalent ❑ Yes ❑ NO Installer,
Box 12 inches Above Grade ❑ Yes ❑ No
Certification#:
Box Adj.To Pump Tank ❑ Yes ❑ No
Conduit Sealed ElYes ElNo *EHS:
Pump Manually Operable ❑ Yes ❑ No
*Activation Method: Date:
Approval Status
Alarm Audible ❑ Yes ❑ o
_Approved❑ Disapproved
Alarm Visible ❑ Yes ;�� N O ,
2140-Nation,Robert
*Operation Permit completed by:
Authorized State Agent:C/ Date of Issue: 0 5 / 2 9 / 2 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 TY'E 11 A. septic system meet the following criteria:
Minimum System Review By The Local Health Department: N/A
Management Entity: OWNER
Maximum System InspectioniMaintenance Frequency By Certified Operator:
NA
Reporting Frequency By Certified Operator. NIA
Rule.1961 requires that a Type IV and V septic systems designed fora hometbusiness owner must maintain a valid contract
with a public management entitywth a certified operatoror a private certified operator forthe life of the septic system.
Rule .1961 requires that Type VI septic systems designed fora hometbusiness 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 public or private management entity, unless the
system ownerand certified operator are the same. The contract shall require specific requirements formaintenance and
operation, responsibilities of the ownerand systems operator,provisions that the contract shall be in effect for as tong 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.
GHand Drawing Olmport Drawing
**Site Pian/Drawing attached.**
OPERATION PERMIT 191 r - 1
Davie County Health Department CDP File Number:
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: !
Q Inch
Drawing Drawing Type: Operation Permit Scale' ' ON A k
I I j I I
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------LL-L
ani � � � ► I
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CONSTRUCTION For Office Use Only
`\� ►' AUTHORIZATION *CDP File Number191976- 1
" Davie Count Health De artment
- r ' Y P County ID Number:
210 Hospital Street Evaluated For: NEW
.�, • .
a.,,.d► P.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone: 336-753-6780 Fax: 336-753-1680 0 4 / 0 a a 0 a 0
Applicant: America's Home Place Inc Property Owner: Caleb Garret Davis
Address: 1206 Green Lane Drive Address:
City: Statesville City:
State/Zip: NC 28677 State/Zip:
Phone#: (704)746-7094 Phone#: (336)978-6192
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
Dorse Road
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY 1-40 West exit 162 turn right onto US-64 EAST 2.7
MILES TURN RIGHT ONTO DAVIE ACADAMEY TURN
#of Bedrooms: 3 RIGHT ON STAGECOACH RD. TURN RIGHT ON
#of People: DORSE ROAD LOT ON LEFT
'Water Supply: NEW WELL
System Specifications
Minimum Trench Depth: a 4
rDesign
ification: Provisionally suitable Inches
Minimum Soil Cover: 1 a
ystem? OYes ®No Inches
w: 3 6 0 Maximum Trench Depth: 3 6
Inches
Soil Application Rate: 0 a 5 Maximum Soil Cover: a 4 Inches
*System Classification/Description: *Distribution Type: GRAVITY-SERIAL
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0
Gallons
*Proposed System: 25%REDUCTION 1-Piece: O Yes ®No
Pump Required: O Yes ®No O May Be Required
Nitrification Field 1 4 4 0
Sq.ft. Pump Tank: Gallons
No. Drain Lines 4 1-Piece: OYes ®No
Total Trench Length: 3 6 0 ft GPM--vs— ft. TDH
Trench Spacing: Inches O.C.
g Feet O.C. Dosing Volume: _ Gallons
Trench Width: 3 Inches
Feet Grease Trap: Gallons
Aggregate Depth:
inches Pre-Treatment: O NSF OTS-1 O TS-II
Septic Tank Installer Grade Level Required: 01011 O III O IV
Page 1 of 3
CDP File Number 191976 - 1 County ID Number: „ J
❑ Open Pump System Sheet
Repair System Required:®Yes ONO ONO, but has Available Space
rDesignFlow.-
System
Trench Spacing: 9 O Inches O.C.
fication: Provisionally suitable — ®Feet O.C.
Trench Width: Inches
3 6 0 — 3 Feet
Soil Application Rate: 0 a Aggregate Depth:a 5 inches
*System Classification/Description: Minimum Trench Depth: a 4 Inches
LTYPE ESS)
A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Minimum Soil Cover: 1 a Inches
*Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches
Nitrification Field 1 6 0 0 Sq.ft. Maximum Soil Cover: a 4 Inches
No. Drain Lines 4 *Distribution Type: GRAVITY-PARALLEL(eq.d-box)
Total Trench Length: 4 0 0 ft. Pump Required: OYes O 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. Rema�r9
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. Rema"�9
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? O Yes ONO
Applicariftegal Reps. Signature- Date:
*Issued By: 2140-Nations,Robert Date of Issue: 0 4 0 a a 0 1 5
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:
L
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 04 / 0a / a015
0 Inch
Drawing Drawing Type: Construction Authorization Scale: . O Block
Q N/A
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CONSTRUCTION AUTHORIZATION
Davie County Health Department S
210 Hospital Street CDP File Number:
P.O.Box 848
Mocksville NC 27028 County File Number:
Date: A4./ 0 . / . 0 15
Click below to import an image from an external location: Drawing Type: Construction Authorization
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