184 Edgewood Circle OPERATION PERMIT or Ice se n v
f Davie County Health Department *CDP File Number 200231 -1
210 Hospital Street
P.O.Box 848 County ID Number.
Mocksville NC 27028 Evaluated For. REPAIR
Phone:336-753.6780 Fax:336-753-1680 Township:
Applicant: Brenda Kinser Property Owner: Brenda Kinser
Address: 184 Edgewood Circle Address: 184 Edgewood Circle
City: Mocksville City: Mocksville
StaterLip: NC 27028 State2ip: NC 27028
Phone#: (336)284-2044 1 Phone#: (336)284-2044
Property Location & Site Information
rAddress/Road#: Subdivision: Edgewood Phase: 1 lot: 63
ewood Circle
le NC 27028 Directions
Stricture: SINGLE FAMILY eft 601 S, Right on Hwy 801 Edgewood Circle on
#of Bedrooms: 4
#of People:
*Water Supply: PUBLIC
*IP Issued by. 'System Classification/Description:
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by: 2140-Nations,Robert SaproliteSystem? QYes QNo
Design Flow: 4 8 0 * GRAVITY-PARALLEL(eq.d-box) Pump Required?
Distribution Type: QYes ONo
Soil Application Rate: 0 , a 7 5 *Pre Treatment:
Drain field
N7Drain
d 1 7 4 5 Sq_ft. *System Type: INFILTRATOR QUICK 4 STANDARD
N 6 Installer: Brian McDaniel
Total Trench Length: 4 3 6 ft. Certification#: 1118
Trench Spacing: — 9 _ ()Inches
O.C.O.C. 'EHS:
2140-Nations.Robert
Trench Width: 3 Ines
ch
&Feet Date: 0 3 / a a / a 0 1 6
Aggregate Depth: inches
Minimum Trench Depth: 3 6
_ Inches
Minimum Soil Covera 4 Inches App`rovalStatus
Maximum Trench Depth: 4 8 ® Approved D Dlsapprovetl.
Inches
Maximum Soil Cover: 3 6 Inches
CDP Fite Number 200231 - 1 Septic Tank County ID Number:
Manufacturer. Lat.
Long:
STB: - - -
Gallons: Installer.
Date: Certification 4:
*EHS:
*Filter Brand:
ST Marker. ❑ Yes ❑ No Date: 1
Reinforced Tank: ❑ Yes ❑ No ApprovalStatus � y
1 Piece Tank: ❑ Yes El No
'❑ APprovedD Disapproved
Pump Tank
Manufacturer. Installer.
PT: Certification#:
Gallons: *EHS:
Date: Date:
RiserSealed ❑ Yes p No
RiserHeght: El Yes ❑ NO (Min.6 in.) 10
Approval Status
Reinforced Tank: El Yes El No
p A-in e'd07 Disapproved
1 Piece Tank: ❑ Yes ❑ No
Supply Line
CPipe Size: inch diameter Installer
Pie Length: feet Certification 9:
*Schedule: *EHS:
Pressure Rated ❑ Yes ❑ NO Date:
Approved fittings ❑ Yes ❑ No ApprovatStatus
❑ Approved') Disapproved
Pump u e
Pump Type: Installer.
Dosing Volume: — Gal Certification#:
Draw Down: Inches *EH S:
*Chau:
Date:
Valves Accessible ❑ Yes ❑ NO
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve ❑ Yes ElNo
Approvat,Status?
PVC unions ❑ Yes ❑ No ❑ Approved E Disapproved
Vent Hole ❑ Yes ❑ No
=>
Anti-siphon Hole El Yes 0 NO
CDP File Number 200231 - 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 ❑ Yes ❑ No *EHS:
Pump Manually Operable ❑ Yes ❑ No
*Activation Method: Date:
Approval Status '-iA
Alarm Audible El Yes El No ❑ ,Approved❑ Disapproved
Alarm Visible ❑ Yes ❑ No
2140-Nations,Robert
*Operation Permit completed by
Authorized State Agent: Date of Issue: 0 3 / a a / 2 0 1 6
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 Ilk 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.
WA
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 for a 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 formaintenance 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 200231 - 1
Davie County Health Department CDP File Number:
210 Hospital Street
County File Number:
P.O.Box 848
Mocksvilie NC 27028 Date: / !
Q Inch
Drawing Drawing Type: Operation Permitr Scale: , ON A k=ft .
0
lifilliiiiiil �
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CONSTRUCTION For office use only
AUTHORIZATION *CDP File Number 200231 -1
Davie County Health Department County ID Number:
210 Hospital StreetEvacuated For: REPAIR
•fes. P.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 0 a / .2 8 a 0 a 1
Applicant: Brenda KinserProperty Owner: Brenda Kinser
Address: 184 Edgewood Circle Address: 184 Edgewood Circle
City: Mocksville City: Mocksville
State/Zip: NC 27028 State/Zip: NC 27028
Phone#: (336)284-2044 Phone#: (336)284-2044
Property Location & Site Information
rAddress/Road,#: Subdivision: Edgewood Phase: 1 Lot: 63
Edgewod Circle
ksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 601 S, Right on Hwy 801 Edgewood Circle on left
#of Bedrooms: 4
#of People:
*Water Supply: PUBLIC
System Specifications
Minimum Trench Depth: a 4
rDesign
sification: Provisionally suitable Inches
Minimum Soil Cover: 1 a
System? OYes 9,No Inches
ow: 4 8 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 02 7 5 Maximum Soil Cover: .2 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:
Gallons
*Proposed System: 25%REDUCTION 1-Piece: O Yes O No
Pump Required: O Yes O No O May Be Required
Nitrification Field 1 3 4 5
Sq.ft. Pump Tank: Gallons
No. Drain Lines 4 1-Piece: OYes ONo
Total Trench Length: 4 3 6 ft GPM--vs— ft. TDH
Trench Spacing: Inches O.C.
— 9 Feet O.C. Dosing Volume: Gallons
Trench Width: 3 Inches
Feet Grease Trap: Gallons
Aggregate Depth:
inches Pre-Treatment: O NSF OTS-I OTS-II
Septic Tank Installer Grade Level Required: 01011 O III ON
Page 1 of 3
CDP File Number 200231 - 1 County ID Number:
❑ Open Pump System Sheet
Repair System Required:0 Yes ®No O No, but has Available Space
CDesign
System
Trench Spacing: O Inches O.C.
fication: — O Feet O.C.
**** 15A NCAC 1 **** 8 Fetes
w:
Soil ApplicationRate: Aggregate Depth: inches
.� Minimum Trench Depth:
*System Classification/DescriInches
Re: pair Area Exe it pt- Inches
Maximum Trench Depth:
*Proposed System: Inches
Maximum Soil Cover:
Nitrification Field Sq.ft. Inches
No.Drain Lines *Distribution Type:
Total Trench Length: 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. Ran
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�,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? Oyes ONo
Applicant/Legal Reps.Signature* _ Date: /
*Issued By: 2140-Nations,Robert Date of Issue: 0 a / a 9 / a 0 1 6
Authorized State Agent: Malfunction Log Oyes
®Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
• CONSTRUCTION AUTHORIZATION 200231 - 1
Davie County Health Department CDP File Number:
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 0 .2 / 29 a 0 1 6
Q Inch
Drawing Drawing Type: Construction Authorization Scale: , OO N/A
7-7 5
G o
4
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Page 3 of 3
P1 P2
DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST
APPLICATION IP/ATC OSWW REPAIR
Name Q/ � Tele hone Number �/-o20yV
/ e
Address M kfcwty,908(de, 1 I
Mailing Address (if different from above)
Email Address:
Subdivision Name Lot#
Directions LIV0
Date System Installed �`'Jo? Name System Installed Under ffiam Of befido
Type Facilitylln use Number Bedrooms Number Pe le Served
Type Wate Supply Specific Problem Occurring d' 6N h5
WW
Date Requested I J , Info Taken By
THIS IS TO CERTIFY THATIrHE 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
r Revisit Charge Date Reason 6s(D A�>l
Revised 2-2011
DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST
-' APPLICATION IP/ATC OSWW REPAIR
Name e �l rysQ� Telephone NumberU77
_
Address a i( ;� �- //
1! 'j
Mailing Address (if different from above)
Email Address:
Subdivision Name Lot#
Directions glljj2 45 Z 0
Date System Installed—Ag Name System Installed Under ISi /Pft Ci
Type Facility .���(j S{/ umber Bedrooms Number Pe le Served
s
Type Wate Supply yLL` Specific Problerri'Occurring d 2molvllo
'j
Date Requested f Info Taken By
THIS IS TO CERTIFY THAT HE INFORMATION^PROVIDED'I&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 -
a
Davie.COUNTY
210 Hospital Street
P.O. Box 848
Mocksville NC 27028 TEL: 336-753-6780 FAX: 336-753-1680 Request ID: 63307
REQUEST FOR SERVICE/COMPLAINT INVESTIGATION REPORT
REQUEST DATE: 02/17/2016 TAKEN BY:
SECTION: N/A TYPE:
PROPERTY NUMBER: 200231 ASSIGNED TO: Nations, Robert
ESTABLISHMENT NUMBER:
PERSON OR PREMISES TO SEE: OWNER: Brenda Kinser
Brenda Kinser 184 Edgewood Circle
184 Edgewood Circle Mocksville , 27028
Mocksville NC, 27028
(336) 284-2044
REQUESTED BY: Homeowner HOME:
WORK:
Cell:
Additional Information:
CONDITION REPORTED:Pumped 2 months ago full again
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: �C\
DATE: HR/MT: COMMENTS
EHS:
EHS #:
ACT CODE:
Next Inspection Date: Status of Complaint: OPEN Resolved Date:
Complaintant Contacted: NO
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