193 Hillcrest DrOPERATION PERMIT
Davie County Health Department
fes. 210 Hospital Street
r
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Jeffrey A. Jones
Address: PO Box 2012
City: Advance
State0l): NC 27006
Phone #: (336) 577-2494
"Address/Road #: Subdivision:
Hillcrest Drive
Advance NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
*Water Supply: NIA
*IP Issued by.
*CA issued by: 2140- Nations, Robert
Design Flow:
Soil Application Rate:
N drification Field
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Aggregate Depth:
(/— t -or umce use Univ
*CDP File Number199685-1
5870892247
County ID Number.
Evaluated For. EXPANSION
Township:
Property Owner. Jeffrey A. Jones
Address: PO Box 2012
City: Advance
State/Zip: NC 27006
Phone #: (336) 577-2494
Phase: Lot: 1
Directions
Hwy 158 right on Hwy 801, Hillcrest on Left
*System Classification/Description:
TYPE IIA. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
SaproliteSystem? (Yes QNo
*Distribution Type: GRAVITY -SERIAL Pump Required?
QYes ONo
*Pre Treatment:
Drain field
1 3 0 9 Sq. ft. *System Type: INFILTRATOR QUICK 4 STANDARD
3 Installer: Jamie Barnes
a 0 0 Certification #: 1018
9 Inches O.C.
Feet O.C. *EM 5: 2140 •Nations, Robert
3 Qlnches
Feet Date: 0 3/ 2 1/ 2 0 1 6
inches
3
6
0
0
.
2
7
5
(/— t -or umce use Univ
*CDP File Number199685-1
5870892247
County ID Number.
Evaluated For. EXPANSION
Township:
Property Owner. Jeffrey A. Jones
Address: PO Box 2012
City: Advance
State/Zip: NC 27006
Phone #: (336) 577-2494
Phase: Lot: 1
Directions
Hwy 158 right on Hwy 801, Hillcrest on Left
*System Classification/Description:
TYPE IIA. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
SaproliteSystem? (Yes QNo
*Distribution Type: GRAVITY -SERIAL Pump Required?
QYes ONo
*Pre Treatment:
Drain field
1 3 0 9 Sq. ft. *System Type: INFILTRATOR QUICK 4 STANDARD
3 Installer: Jamie Barnes
a 0 0 Certification #: 1018
9 Inches O.C.
Feet O.C. *EM 5: 2140 •Nations, Robert
3 Qlnches
Feet Date: 0 3/ 2 1/ 2 0 1 6
inches
CDP File Number 199685 -1 County ID Number: 5870892247
Electric EQuiDment
NEMA 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
*EHS:
Pump M anually 0 perable
❑
Yes
❑
No
*Activation Method:
Date:
,
Alarm Audible
❑Yes
❑
No
Q
Approval Status % .
Approved ❑ ,Disapproved
Alarm Visible
❑
Yes
❑
No
2140 - Nations. Robert
*Operation Permit completed by: �f
Authorized State Age o - -�.�// __ _,.�� _ Date of Issue. 3 a 1 i' a 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 IIA.
septic system most the following criteria:
Minimum. System Review By The Local Health Department: DIA
Management Entity: OWNER
-- Minimum System Inspection/Maintenance Frequency ByCertified Operator:
WA
Reporting Frequency By Certified Operator. N/A
Rule .1961 requires that a Type IV and V septic systems designed fora hometbusiness 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 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 owner and 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.
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
CONSTRUCTION
AUTHORIZATION
- Davie County Health Department
t t „ 210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Jeffrey A. Jones
Address: PO Box 2012
City: Advance
State/Zip: NC
Phone #: (336) 577-2494
27006
Property Owner: Jeffrey A. Jones
Address: PO Box 2012
City: Advance
State/Zip: NC
Phone #: (336) 577-2494
Property Location & Site Information
("'Address/Road #: Subdivision:
Hillcrest Drive
Advance NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
\ `Water Supply: N/A
27006
Phase: Lot: 1
Directions
Hwy 158 right on Hwy 801, Hillcrest on Left
m Specificati
Classification:
Provisionally suitable
Minimum Trench Depth:
a 4 Inches
\Site
Minimum Soil Cover:
1 a
Saprolite System?
O Yes (9No
Inches
Design Flow:
3 6 0
Maximum Trench Depth:
3 6 Inches
Soil Application Rate:
0 a 7
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:
O Yes O No
Pump Required: O Yes
O No O May Be Required
Nitrification Field
4
3
6 Sq. ft. Pump Tank:
Gallons
No. Drain Lines
1
1 -Piece:
OYes ONo
Total Trench Length:
1 0 9
GPM --vs— ft. TDH
ft
Trench Spacing:
_
9
Inches O.C.
Feet O.C. Dosing Volume:
Gallons
Trench Width:
3
OInches
�1 Feet
_
Grease Trap:
Gallons
Ag gregate Depth:
inches Pre -Treatment: O NSF OTS -1 O TS -11
Septic Tank Installer Grade Level Required: 01011 O III 01V /
Page 1 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Construction Authorization
CDP File Number: 199685 - 1
County File Number: 5870892247
Date: 03/11/a016
Q Inch
Scale: O Block
O N/A
Page 3 of 3
P1 P2
Davie Counter Health Depm-b-nent
418I� F�lviranmental Health Section C
P.O. Box 848
GD210 Hospital Street
U '4 Courier # : 09-40-06
tau:1\locksville, NC 27028
'hone: (336) - 753 - 6780 Far: (336) - 753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling econnectio
Name: J �� F�q- y �� v. � Phone Number 3 S % Y2Y (Home)
Mailing Address: O rl � K (Work)
Detailed Directions To Site: In V •e Ll b EA C ( J p ' (� �� J j �-4 - � ,, � ,y 9 / G /.,F-7 61\j
S,
we
Property Address: " I - It' - Z Lo fs 1 _
Please Fill In The Following Information About The EXISTING Facility: 2
L17
Name System Installed Under: Type Of Facility:
Date System Installed (Month/Date/Year): Number Of Bedrooms: 3 Number Of People: q{ L, J�
Is The Facility Currently Vacant? es) No If Yes, For How Long?_ U �ti2 S
Any Known Problems? Yes No If Yes, Explain:
Please Fill In The Following Information About The NETVFacility:
Type Of Facility: (i) 1Rc9 MF l�c9 1 [✓ t » 7 Number Of Bedrooms: Number of People 3 - -5
Pool Size: Q Garage Size: 41 Other: —
Requested By:
(Signa
Approved Disapproved
Comments:
Requested: i - -L C' - 1.5 -
For Environmental Health Office Use Only
Environmental Health Specialist Date:
*The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee
(extended or limited) that the on-site wastewater system will function properly for any given period of time.
payment: Cash Check Money Order #
Amomit:$
?aid By: i Y f Received By:_
bkccount #: p 7 Invoice #:
Date: