220 Gun Club RdOPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Robert and Andrea Duggins
Address: 2751 Shober Court
City: Winston-Salem
State/Zip: NC 27127
Phone #: (336) 477-2994
Propertv Location &
Address/Road #: Subdivision:
220 Gun Club Rd
Advance NC 27006
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
*Water Supply: PUBLIC
*IP Issued by. 2140 - Nations, Robert
*CA issued by: 2140 - Nations, Robert
Design Flow: 3 6 0
Soil Application Rate: 0 a 7 5
Nitrification Field
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Aggregate Depth:
'CDP File Number 187548-1
County ID Number.
Evaluated For. NEW
Township:
Property owner: Robert and Andrea Duggins
Address: 2751 Shober Court
City: Winston-Salem
State2ip: NC 27127
Phone #: (336) 477-2994
Phase: Lot:
Directions
hwy 158 East, right on Gun Club Rd, property on
right
*System Classification/Description:
TYPE 11 A CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
SeproliteSystem? OYes (!)No
'Distribution Type: GRAVITY- SERIAL Pump Required?
OYes,oNo
*Pre Treatment:
rain
1 3 0 9 Sq. ft.
4
3 2 7 ft.
9 Inches O.C.
Feet O.C.
3 Inches
Feet
inches
Minimum Trench Depth: 3
6
Minimum Soil Cover. 2
4
Maximum Trench Depth, 3
1
6
Maximum Soil Cover: a
4
Inches
Inches
Inches
Inches
*System Type: INFILTRATOR QUICK 4 STANDARD
Installer: Frank Transou
Certification #: 2771
'EH S: 2140 - Nations. Robert
Date: 0 3/ 1 5/ 2 0 1 6
Approval Status
O Approved O Disapproved
CDP File Number 187548 ` 1
Manufacturer. Shoat
STB: 760
Gallons: 1000
Date:
1;2/
❑
0 5/
a 0 15
'Filter Brand:
POLYLOK PL -122 With Pipe Adapter
ST Marker:
❑
Yes
O
No
Reinforced Tank:
❑
Yes
M
No
11_',_P iece Tank:
❑
Yes
M
No
Manufacturer.
PT:
Gallons:
Date:
County ID Number:
c TanK
Lat.
Long:
Installer-. Frank Transou
Certification #: 2771
*EH S:
Date: 0 3/ 1 5/ 2 0 1 6
Approval Status
® Approved ❑ Disapproved
Pump Tank
Riser Sealed ❑
Yes
❑
No
Riser Height: ❑
Yes
❑
NO (Min.6 in.)
nforced Tank: ❑
Yes
❑
NO
1 Piece Tank: ❑
Yes
❑
No
/ Pipe Size: inch diameter
Pipe Length: feet
`Schedule:
Pressure Rated ❑ Yes ❑ No
Approved fittings ❑ Yes ❑ No
Installer:
Certification 9:
*EHS:
SUDDIV
Date:
Approval Status
❑ Approved ❑ Disapproved
,ine
Installer:
Certification #:
*EHS:
Date:
Approval Status
❑ Approved ❑ Disapproved
Pump Type: Installer.
Dosing Volume: - Gal Certification A!:
Draw Down: Inches *EH S:
*Chain:
Date: I /
Valves Accessible
❑ Yes
❑
No
Flow Adjustment Valve
❑ Yes
❑
No
Check -valve
❑ Yes
❑
No
Approval Status.
PVC unions
❑ Yes
❑
No
❑ Approved ❑ Disapproved
Vent Hole
❑ Yes
❑
No
Anti -siphon Hole
❑ Yes
0
No
CDP File Number 187548-1
ciectric cuurument
County ID Number:
N EMA 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 'ENS:
Pump Manually Operable
❑ Yes
❑
No
*Activation Method:
Date: /
Alarm Audible ❑ Yes
Alarm Visible ❑ Yes
'Operation Permit completed by.
Authorized State Agen
El No Approval Status
❑ Approved ❑ Disapproved
❑ No
2140 - Nations, Robert
Date of Issue: 0 3/ 1 5/ x 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 it A. 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:
N/A
Reporting Frequency By Certified Operator: MIA
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 entitywith a certified operatoror a private certified operator forthe 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 entitywith 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.
OHand Drawing 41mport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC
Drawing Drawing Type: Operation Permit
CDP File Number: 187548 -1
County File Number:
27028 Date:
% --- A ---J
Olnch
Scale:. OBtock ft.
ON/A
51�
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0;7 Z-
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........._..........
cf
CONSTRUCTION
` ,AUTHORIZATION
Davie County Health Department
�✓ 210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Robert and Andrea Duggins
Address: 2751 Shober Court
City: Winston-Salem
State/Zip: NC 27127
Phone #: (336) 477-2994
/ For Office Use Only
*CDP File Number 187548 - 1
County ID Number:
Evaluated For: NEW
Township:
PERMIT VALID UNTIL:
Property Owner:
Robert and Andrea Duggins
Address:
2751 Shober Court
City:
Winston-Salem
State/Zip:
NC 27127
Phone #:
(336) 477-2994
Property Location & Site Information
Address/Road M Subdivision:
220 Gun Club Rd
Advance NC 27006
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
*Water Supply: PUBLIC
Phase: Lot:
Directions
hwy 158 East, right on Gun Club Rd, property on right
Page 1 of 3
Minimum Trench Depth:
a 4 Inches
\Site
Classification:
Provisionally suitable
Minimum Soil Cover:
1 a
Saprolite System?
OYes ® No
Inches
Design Flow:
3 6 0
Maximum Trench Depth:
3 6 Inches
Soil Application Rate:
0 .2 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:
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 3
0
9 Sq. ft.
Pump Tank:
Gallons
No. Drain Lines
3
1 -Piece:
OYes ONo
Total Trench Length:
3 a 7
GPM --vs-- ft. TDH
ft
Trench Spacing:
—9
® Olnches O.C.
Feet O.C.
Dosing Volume:
— Gallons
Trench Width:
3
0Inches
—
® Feet
Grease Trap:
Gallons
Aggregate Depth:
inches
Pre -Treatment: O NSF OTS -1 OTS -11 /
Septic Tank Installer Grade Level Required: 01011
O 111 01V `
Page 1 of 3
CDP File Number 187548 - 1
Repair System Required: ®Yes
County ID Number: I ., I
❑ Open Pump System Sheet
O No ONo, but has Available Space
Repair System
Trench Spacing:
9 O Inches O.C.
*Site Classification: Provisionally suitable
—
® Feet O.C.
Design Flow:
Trench Width:
Inches
3 Feet
3 6 0
_
Aggregate Depth:
Soil Application Rate:0 a7 5
inches
Minimum Trench Depth:
a 4
*System Classification/Description:
Inches
A. CONY SYSTEM (SINGLE -FAMILY OR 480 GPD OR Minimum Soil Cover:
1 a
LTYPE ESS)
Inches
Maximum Trench Depth:
3 6
*Proposed System: 25% REDUCTION
Inches
Maximum Soil Cover:
a 4
Nitrification Field 1 3 0 9
Inches
Sq. ft.
No. Drain Lines3
*Distribution Type:
GRAVITY - PARALLEL (eq. d-box)
Total Trench Length: 3 6 0
Pump Required: OYes
®No O May Be Required
ft
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. Rene�`ing
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. Characters
Remaining
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 O No
Applicant/Legal Reps. Signature: Date: /
*Issued By: 2140 - Nations, Robert Date of Issue: 0 7 / a 0 / 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
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
CDP File Number: 187548 - 1
County File Number:
Date: 07 /.1 0/2015
O Inch
Rr`alp' n Rlnck
ft
Page 3 of 3
P1 P2
Ce
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
CDP File Number: 187548 - 1
County File Number:
Date: ATS. 0 /�.a.0.1.5.
Click below to import an image from an external location: Drawing Type: Construction Authorization
Page 3 of 3
P1 P2
F � '
IMPROVEMENT PERMIT
.�, Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
For Office Use Only
*CDP File Number 187548 -1
County ID Number:
Evaluated For: NEW
`Township:
Phone: 336-753-6780 Fax: 336-753-1680
PERMIT VALID UNTIL: 1/29/2020
*NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit.
Applicant: Robert and Andrea Duggins
Address: 2751 Shober Court
City: Winston-Salem
State/Zip: NC 27127
Phone #: (336) 477-2994
Address/Road #:
216 Gun Club Rd
Advance NC 27006
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
*Water Supply: PUBLIC
Property Owner: Robert and Andrea Duggins
Address: 2751 Shober Court
City: Winston-Salem
State/Zip: NC 27127
Phone #: (336) 477-2994
ierty Location & Site Information
Subdivision: Phase: Lot:
Initial S stem
*Site aSss Ica ion: PS Shallow Placement
Saprolite System? O Yes 69 No
Design Flow: 3 6 0
Soil Application Rate: 0 a 7 5
*System Classification/Description:
TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR
*Proposed System: 25% REDUCTION
Directions
hwy 158 East, right on Gun Club Rd, property on
right
Minimum Trench Depth: a 4 Inches
Maximum Trench Depth: 3 6 Inches
Septic Tank: 1 0 0 0
Gallons
1 -Piece: OYes ®No
Pump Required: OYes (9 No O May Be Required
Pump Tank: Gallons
1 -Piece: O Yes O No
Repair System Required: ®Yes ONo ONo, but has Available Space
Repair System
*Site Classification: Provisionally Suitable
Soil Application Rate: 0 a 7 5
*System Classification/Description:
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR
LESS)
*Proposed System: 25% REDUCTION
Minimum Trench Depth: a 4 Inches
Maximum Trench Depth: 3 6 Inches
Pump Required: OYes ® No O May be Required
Page 1 of 3
CDP File Number 187548 - 1
County ID Number:
*Site Modifications ❑ Open Fill Sheet
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. Remains
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. Character.
750
The Improvement Permit shall be valid for 5 years from date of issue with a site plan (means a drawing not necessarily drawn to
Site Plan scale that shows the existing and proposed property lines with dimensions, the location of the facility and appurtenances, the
(9 site for the proposed Wastewater system, and the location of water supplies and surface waters).
Plat The Improvement Permit shall be valid without expiration with plat (means a property surveyed prepared by a registered land
surveyor, drawn to a scale of one inch equals no more than 60 feet, that includes: the specific location of the proposed facility
O and appurtenances, the site for the proposed Wastewater system, and the location of water supplies and surface waters. Plat
also means, for subdivision lots approved by the local planning authority and recorded with the county register of deeds, a copy
of the recorded subdivisions plat that is accompanied by a site plan that is drawn to scale).
The Department and Local Health Department may impose conditions on the Issuance and may revoke the permits for failure of
the system to satisfy the conditions, the rules, or this article. This permit is subject to revocation if the site plan, plat, or intended
use changes (NCGS 130A -335(Q). 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 1 / a 9 / a 0 1 s
Authorized State A-- OValid without Expiration?
O Create CA?
® Hand Drawing O Import Drawing
*Site Plan/Drawing attached.**
Page 2 of 3
IMPROVEMENT PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Impro Permit
CDP File Number. 187548 -1
County File Number:
Date: / /
O Inch
Scale: O Block
O N/A
Page 3 of 3
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Page 3 of 3
P1 P2
IMPROVEMENT PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
CDP File Number: 187548 - 1
County File Number:
Date: .0.1,/ .19 / a 0 15
Click below to import an image from an external location: Drawing Type: Improvement Permit
Page 3 of 3
P1 P2
ti � ON F R SITE EVALUATION/IMPROVEMENT PERMIT & ATC
4g(g; Davie County Environmental Health
P.O. Box 848/210 Hospital Street RECEIVED
Mocksville, NC 27028
(336)753-6780/ Fax (336) 753-1680 DEC 3 n 2014
Application For: C Site Evaluation/Improvement Permit k Authorization To Construct(ATC) C Both U '1
Type of Application: ;ONew System ❑Repair to Existing System CExpansion/Modification of ExisD0sHE ¢ tT* H
s«*IMPORTANT••• THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED -1 C/yL
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed Robert and Andrea Duggins Contact Person Andrea Duggins
Billing Address 2751 Shober Court Home Phone 336-775-2994
City/State/ZIP Winston-Salem, NC 27127 Business Phone 336-817-3047
Name on Permit/ATC if Different than
Mailing Address
t'KUYbK1 1NfUK1V1A11UN Late rtousemacuny t;orners riaggea
NOTE: A sui vey plat or site plan must accompany this application. Included: XSite Plan CPlat(to scale)
(Pen.iit is valid for 60 months with site plan, no expiration with complete plat.)
Owner's Name Robert and Andrea Duggins Phone Number 336-775-2994
Owner's Ad6reSS 2751 Shober Court City/State/Zip Winston-Salem, NC 27127
Property Address 216 Gun club Read City Advance
Lot Size 8.910 Acres Tax PIN# 5861974146
Subdivision Name(if applicable) Section/Lot#
Directions To Site: Highway 801 N, turn right onto US -158W, travel 1.4 miles, turn right onto Gun Club Road, travel .4 miles, turn right 216 Gun Club Road
If the answer to any of the following questions is "yes", supporting documentation must be attached.
Are there any existing wastewater systems on the site?
$Yes CNo
Doe-; the site contain jurisdictional wetlands?
❑Yes XNo
Are there any easements or right-of-ways on the site?
❑Yes DC Jo
Is the site subject to approval by another public agency?
[]Yes [XNo
Will wastewater other than domestic sewage be generated?
❑Yes NIo
IF RESIDENCE FILL OUT THE BOX BELOW
# People 3 # Bedrooms 3 # Bathrooms 25 Garden Tub/Whirlpool GYes ❑No
Basement: ❑Yes VNo Basement Plumbing: El Yes Wo
IF NON -RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business Total Square Footage of Building # People
#Sinks # Commodes # Showers # Urinals
Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: # Seats
Type system requested: .-+ Conventional ❑Accepted ❑Innovative CAlternative ❑Other
Water Supply Type: ;(County/City Water C New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? C Yes
If yes, what type?
XNo
This is to certify that the information provided on this application is true and correct to the best of my knowledge. 1 understand
that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use
changes, or if :he information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized
Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable
laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and
I4 tin i jd a_gging o� in he /sp facility location, proposed well location and the location of any other amenities.
Property owner's legal repr entative signature Site Revisit Charge
IdI�I'' u Client ):
I 1 Client Notification Date:
Date EHS:
Sign given GYes CNo
Revised 11/06
Account # 1 U 7 a F
Invoice #
_i :::;
::::;:.::
Robert and Andrea Duggins
336 775-2994
DAVIE COUNTY HEALTH DEPARTM
Environmental Health Section
Soil/Site Evaluation
PROPERTY INFORMATION
Gun Club Road
5861974146
8.910 Acres
Water Supply: On ite W 1 Community !
Evaluation By: Auger Boring Pit
E i
Public
FACTORS 1
2
3 4
5 6 7
Landscape position
Slope % (
i
HORIZON I DEPTH O
-- Z
=-
Texture group i C_
Consistence
N—
Structure
Mineralogy
HORIZON H DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy{
HORIZON IV DEPTH 1
l
Texture groupI
Consistence i
f
Structure }
MineralogyI
1
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE i
1
CLASSIFICATION 1.
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE
REMARKS:
�_
RATE: � ' Z 5
EVALUATION BY.
OTHER(S) PRESENT:
;
U S
' LEGEND
R - Ridge S - Shoulder I L - Linear slope FS - Foot slope N - Nose slope,
CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H';- Head slope
Texture
S - Sand LS - Loamy sand SL - Sandy loam L - Loam SI - Silt
SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam
SC - Sandy clay SIC - Silty clay C - Clay
CONSISTENCE
Moist ! �
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
Yet i
NS - Non sticky SS -Slightly sticky S - Sticky VS - Very Sticky
NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic 1
j •.
Structure
SC - Single grain M - Massive CR - Crumb GR - Granular ABK -Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic i
� I
Mineralogy
1:1, 2:1, Mixed j
Horizon depth - In inches 1
Depth of fill - In inches
Restrictive horizon - Thickness' and inches from land surface
Saprolite - S(suitable), U(unsuitable)
Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less
Classification - S(suitable), PS(provisionally suitable), U(unsuitable)
TTAT T -.. .___ ____________ ___ __1l�___lC.n """'-_-� "_•_- •—