156 Duard Reavis Rd • r
OPERATION PERMIT or I ice use unly,
Davie County Health Department *CDP File Number 136728
210 Hospital Street D24OM00.013-04
P.O. Box 848 County ID Number
Mocksville NC 27028 Evaluated For. REPAIR
Phone:336-753-6780 Fax:336-753-1680 Township:
Applicant: Annette Hempstead
r
erty owner. Annette Hempstead
F
Address: 156 Duard Reavis Rd ress: 156 Duard Reavis Rd
Czy: Mocksville Cky: Mocksville
StatefLip: NC 27028 StatefZip: NC 27028
Phone#: Phone#:
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
Annette Hempstead
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY : Hvvy 601 North, left on Liberty Ch Rd. the left on Bear
Creek Rd. the right on Durard Reavis Rd. on Right
of Bedrooms: past Timber trails. home on right
#of People:
*Water Supply: ruA
*IP Issued by. 'System Classification/Description:
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by: 2140-Nations,Robert Saprolite System? Q Yes ( No
Design Flow: 3 6 0 *DistributionType: GRAVITY-SERIAL Pump Required?
QYes ONo
Soil Application Rate: 0 2 7 5 *Pre Treatment:
Drain field
FNo.
on Field 1 3 0 9 Sq. ft. *System Type: INFILTRATOR QUICK 4 STANDARD
n Lines aInstaller: Shemin Dunn
,
Total Trench Length: 4 0 0 Certification#: 2702
Trench Spacing: — 9 Inches O.C.
()Inches
O.C. *EH S: 2140-NaWns.Robert
Trench Width: 3 Inches
— Feet Date: 0 7 / 1 0 / 2 0 1 4
Aggregate Depth: inches
Minimum Trench Depth: 3 6
_ _ Inches
Minimum Soil Cover. 4 Inches Approvat,Status'
Maximum Trench Depth: 3 6 ® App"r"ovetl Cl Disapproved
Inches
Maximum Soil Cover: 4
Inches
CDP File Number 136728 - 1 County ID Number: D2.000-00-013-,04
Septic Tank
Manufacturer. Lat.
STB: Long:
Gallons: Installer.
Date: Certification#:
*EHS:
*Filter Brand: POLYLOK PL-122 With Pipe Adapter
ST Marker. ❑ Yes ❑ No Date:
,
Reinforced Tank: ❑ Yes ❑ No n Approval Status 3
1 Piece Tank: ❑ Yes ❑ No a Approved❑-*Disapproved
Pump Tank
Manufacturer. Installer:
PT: Certification#:
Gallons: *EHS:
Date: Date:
RiserSealed ❑ Yes ❑ No
RiserHeght: ❑ Yes ❑ No (Min.6 in.) rApproval Status
einforced Tank:.❑ Yes ❑ No ❑ Approved❑ Disapproved
1 Piece Tank: ❑, Yes ❑ NO - 3 -f
Supply Line
FPiope
ize: inch diameter Installer.
gth: feet Certification 9:
Schedule: *ENS:
Pressure Rated ❑ Yes ❑ No Date.
Approved fittings ❑ Yes ❑ No Approval Sfatus
❑ Approved❑ Disapjaroved
' .
Pump 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 Approval`Sfatus-
PVC unions ElYes ❑ No ❑ Approved Disapproved
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole ❑ Yes 0 No
CDP File4Jumber 136728 - 1 County ID Number: °2.000-00-013-04
Electric Equipment
NEMAT or Equivalent ❑ Yes ❑ No Installer:
Box 12 Above Grade ❑ Yes ❑ No
Certification#:
Boo Pump Tank ❑ Yes ❑ No
Conduit Sealed ❑ Yes ❑ No 'EHS:
Pump Manually Operable ❑ Yes ❑ No 1
*Activation Method: Date:
Approval Status
_
Alarm Audible ❑ Yes ❑ No O Approved❑ [ Isapproired
Alarm visible E] Yes ❑ NO
2140 aeons,Robert
*Operation Permit completed by:
Authorized State Agen - Date of Issue: 9 a 0 1 4
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,I 5 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: WA
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 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 fora homelbusiness 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 Olmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT 136728-1
Davie County Health Department CDP File Number:
210 Hospital Street D2-000-00-013-0=t
P.O.Box as County File Number:
Mocksville NC 27028 Date: / /
Olnch
Scale: . OBlock
Drawing Drawing Type: Operation Permit ONIA
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• CONSTRUCTION For office use only
AUTHORIZATION *CDP File Number, 136728-1
Davie County Health Department County ID Number: D2-000-00-013-04
210 Hospital Street Evaluated For: REPAIR
..�a• e,. P.O. Box 848
Township:..
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 0 3 / a 5 a 0 1 9
Applicant: Annette Hempstead Property Owner: Annette Hempstead
Address: 156 Duard Reavis Rd Address: 156 Duard Reavis Rd
City: Mocksville City: Mocksville
State/Zip: NC 27028 State/Zip: NC 27028
Phone#: Phone#:
Property Location &Site Information
Address/Road M Subdivision: Phase: Lot:
Annette Hempstead
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 601 North, left on Liberty Ch Rd.the left on Bear
Creek Rd.the right on Durard Reavis Rd. on Right past
#of Bedrooms: Timber trails. home on right
#of People:
'Water Supply: NSA
System Specifications
Minimum Trench Depth: a 4, Inches
rDesign
ification: Provisionally suitable
Minimum Soil Cover: 1 a
ystem? OYes tgNo Inches
w: 3 6 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 a 3 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:
Gallons
*Proposed System: 25%REDUCTION 1-Piece: OYes O No
Pump Required: OYes (&No O May Be Required
Nitrification Field 1 3 0 9 Sq.ft. Pump Tank: Gallons
No. Drain Lines 3 1-Piece: OYes ONo
Total Trench Length: 3 a 7 ft GPM—vs— ft. TDH
Trench Spacing: g
_ R Inches O.C.
Feet O.C. Dosing Volume: Gallons
Trench Width: _ 3 Olnches
®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 136728- 1 County ID Number: D2-000-00-013-04
❑ Open Pump System Sheet
Repair System Required:0 Yes ONO O No, but has Available Space
CDesign
System
Trench Spacing: 9 O Inches O.C.
fication: Provisionally Suitable — ®Feet O.C.
Trench Width: O Inches
w: 3 6 0 - 3 ®Feet
Soil Application Rate: OAggregate Depth: inches
.
.� a � S
*System Classification/Description: Minimum Trench Depth: .2 4 Inches
LESS)TYPE II A.CONV 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 3 0 9 Sq.ft. Maximum Soil Cover: a 4 Inches
No.Drain Lines 3 *Distribution Type: GRAVITY-SERIAL
Total Trench Length: 3 a 7 ft Pump Required: OYes i$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
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 m"�g
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 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(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 O No
Applicant/Legal Reps.Signature- Date:
*Issued By: 2140-Nations,Robert Date of Issue: 0 3 .2 5 a 0 1 4
42
Authorized State Agent: Malfunction Log Oyes
®Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION 136728 - 1
Davie County Health Department CDP File Number:
210 Hospital Street D2-000-00-013-04
P.O.Box 848
County File Number:
Mocksville NC 27028 Date: 0 3 / ,25 / .1014
0 Inch
Drawing Drawing Type: Construction Authorization Scale: . O Block
O N/A
G
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• CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street CDP File Number: 136728 - 1
P.O.Box 848 D2-000-00-013-04
Mocksville IVC 27028 County File Number:
Date: .113./ a 5 / a 0 14
Click below to import an image from an external location: Drawing Type: Construction Authorization
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