827 Fairfield Rd (2) OPERATION PERMIT EEvaluatedFoc
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,..�vr.
Davie County Health Department 210 Hospital Street 000501
P.O.Box 848.'��. Mocksville NC 2702$ WPhone:336-753-6780 Fax:336-753-1680
Applicant: Tony Capote Builders
rAddrerss-:O'
ety ner: Yvonne Fink and Jackson Glover
Address 5426 Capote Road 172 Canterbury Place
City: Mocksville City: Mooresville
StatefLip: NC 27028 State2ip: NC 28115
Phone#: (704)483-7313 Phone#:
PropeLbj Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
Will Boone Road i 7
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY 601 s. left on Fairfield Road, Go to end, property on
corner on left.
#of Bedrooms: 4
#of People: 3
*Water Supply: PUBLIC
*IP Issued by *System Classification/Description:
TYPE It A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by:
SaproliteSystem? OYes ONo
Design Flow: 4 8 0 * GRAVITY-SERIAL. Pump Required?
Distribution Type: OYes GNo
Soil Application Rate: 0 a 5 *Pre Treatment:
Drain field
(No.
�rification Field 1 9 a 0 S4• *System Type: INFILTRATOROUICK4STANDARD
Drain Lines 6 Instaher: Shannon Henderson
otal Trench Length: 4 8 0 ft- Certification#: 1091
Trench Spacing: _ 9 Inches O.C.
Feet O.C. *ENS: 2140-Nations.Robert
Trench Width: _ 3 Olnches
QFeet Date: 1 0 / 1 1 / 2 0 1 3
Aggregate Depth: inches
Minimum Trench Depth: 3 6
. Inches
Minimum Soil Cover. 4 Approval Status
Inches ,
Maximum Trench Depth: 3 6 Inches
® Approved Qlsapproved
Maximum Soil Cover: 2 4
Inches
CDP File Number 120601 - 1 Septic Tank County ID Number: L60000000501
Manufacturer. Shoaf Lat.
STB; 760 Long: _ . • - - .
Installer
Henderson
Gallons: 1000
Certification#: 1091
Date: 0 8 / 0 7 / 2 0 1 3
*EHS: 2140-Nations.Robert
*Filter Brand: POLYLOK PL-122 With Pipe Adapter
ST Marker. E] Yes ❑ No Date: 1 0 / 1 1x 0 1 3
/
Approval Status
Reinforced Tank: ❑ Yes ❑ NO
® Approved❑ D15appraved3.
1 Piece Tank: ❑ Yes ❑ No �
Pump Tank
Manufacturer. Installer.
PT: Certification#:
Gallons: *EHS:
Date: / / Date:
Risersealed ❑ Yes ❑ No
RiserHeght: ❑ Yes ❑ No (Min.6 in.)
Approval Status,
einforced Tank: ❑ Yes [� No ❑ Approved❑: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 D.,-,,Di d
i
PjAmp
e
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 El Yes ❑ No ❑ Approved❑ Disapproved
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole ❑ Yes ❑ NO
CDP File Number 120601 - 1 County ID Number: L6000000050t
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:
Alarm Audible ❑ Yes_ El No Approval Status -
❑ Approved❑ Disapproved ,
- Alarm Visible ❑ Yes ❑ No
2140-Nations.Robert
*Operation Permit completed by:
Authorized State Agen . Date of Issue: 1 0 / 1 1 / 2 0 1 3
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 T1ePE 11 A. sewage septic system.
Rule.1961 requires that a Type rfPE n a septic system meet the following criteria: -
Minimum System Review By The Local Health Department: NIA
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency By Certified Operator:
N/A
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 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 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.**
V
OPERATION PERMIT 120601 - 1
Davie County Health Department CDP File Number:
210 Hospital Street L60MOO501
P.O.Box Bas County File Number:
Mocksville NC 27028 Date: ! /
0Inch
Scale: QSbck
Drawing Drawing Type: Oper ion Permit ON/A
3
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Exhibit "A" Levis
BEGINNING at an iron stake found at the ri
being at the southern comer of the within d
Property of Robert J.Wescott,Jr.,as descri
right of way of said highway North 4S degn
stake set; thence North 56 degrees 14 mint
set,an internal corner; thence North 45 dei
new Iron stake act in the property line with t
Book 126 at page 760,the Western corner of
Property North S I degrees 52 minutes 32 se
Southern bank of brunch in the property line
Deed Book 82 at page 34,the Northern cor
Call line South 51 degrees o9 minutes 10 Seco
southern bank of a branch,said bent iron bein
West 88.01 feet from a rebar found,said bent
described parcel; thence with the Wescott rm
645.99 feet to an iron stake found;thence Sou
fat TO THE POINT AND PLACE OF BEG
Grady L.Tutterow,RLL,and being taken fro
in Deed Book 172 at page 572,and is part of
County Registry. 4/97/lh
CONSTRUCTION For Office Use Only
AUTHORIZATION *CDP File Number 120601 - 1
Davie County Health Department L60000000501
,�°�""• ''� tY P County ID Number:
t 210 Hospital Street Evaluated For: NEW
•� o,. P.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 08 / .18 / .1018
Applicant: Tony Capote Builders Property Owner: Yvonne Fink and Jackson Glover
Address: 5426 Capote Road Address: 172 Canterbury Place
City: Mocksville City: Mooresville
State/Zip: NC 27028 State/Zip: NC 28115
Phone#: (704)�481-73�13 Phone#:
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
Will Boone Road
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY 601 s. left on Fairfield Road, Go to end, property on
comer on left.
#of Bedrooms: 4
#of People: 3
*Water Supply: PUBLIC
System Specifications
Minimum Trench Depth: a 4
rDesign
cation: Ps Inches
Minimum Soil Cover:
stem? OYes ®No Inches
4 8 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 . a 5 Maximum Soil Cover: Inches
*System Classification/Description: *Distribution Type: GRAVITY-SERIAL
TYPE II A.CONY 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
Sq.ft. Pump Tank: Gallons
No. Drain Lines 1-Piece: OYes ONo
Total Trench Length: 4 8 0 ft GPM—vs— ft. TDH
Trench Spacing: g
_ O Inches O.C. Dosing Volume: _ Gallons
_ 8Feet O.C.
Trench Width: Inches
Aggregate Depth: _ _ 8Feet Grease Trap: Gallons
inches Pre-Treatment: O NSF OTS-1 OT
S-II
Septic Tank Installer Grade Level Required: O1OII OIII OIV
Page 1 of 3
CbP File Number 120601 - 1 County ID Number: L60000000501
❑ Open Pump System Sheet
Repair System Required:®Yes O No ONO, but has Available Space
CDesign
System
Trench Spacing: Inches O.C.
fication: Ps — Feet O.C.
Trench Width: Inches
: 4 8 0 _ Feet
SoilApplication Rate: 0 a 5 Aggregate Depth: inches
.�
*System Classification/Description: Minimum Trench Depth: Inches
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Minimum Soil Cover:
LESS) Inches
*Proposed System: 25%REDUCTION Maximum Trench Depth: Inches
Maximum Soil Cover:
Nitrification Field Inches
Sq.ft.
No. Drain Lines *Distribution Type: PUMP TO GRAVITY
Total Trench Length: 4 8 0 ft Pump Required: ®Yes 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.
*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 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 ®No
Applicant/Legal Reps. Signature: Date:
*Issued By: 2244-Daywalt,Andrew Date of Issue: 0 8 / a 8 / a 0 1 3
Authorized State Agent: W�W�W Malfunction Log OYes
®Hand Drawing O Import Drawing Total Time:(HH:MM)
**Site Plan/Drawing attached.** 0 1 Hours 0 0 Minutes
Page 2 of 3
S-8-CA'S issued-new
CONSTRUCTION AUTHORIZATION
Davie County Health Department CDP File Number: 120601 - 1
210 Hospital Street L60000000501
P.O.sox 848 County File Number:
Mocksville NC 27028 Date: 08 / a8 / .2013
O Inch
Drawing Drawing Type: Construction Authorization Scale: 7 O Block
/A
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Page 3 of 3
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• CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street CDP File Number: 120601 - 1
P.O.Box 848 L60000000501
Mocksville NC 27028
County File Number:
Date: 0.8..,/,.2 8. .a.01.3.
Click below to import an image from an external location: Drawing Type: Construction Authorization
Page 3 of 3
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