4264 Hwy 158 OPERATION PERMIT or ficeuseunlV
Davie County Health Department *CDP File Number 192787-1
®r((, 210 Hospital Street
P.O. Box 848 County Il]Number,Mocksville NC 27028 Evaluated For. REPAIR
Phone:336-753-6780 Fax:336-753-1680 Township:
7Address:
ant: Ruby Lyons r
operty Owner: Ruby Lyons
4264 US Hwy 158 ddress: 4264 US Hwy 158
yAdvance ty: Advance
State)Zip: NC 27006 State/Zip: NC 27006
Phone#: (336)998-3627 1,Phone#: (336)998-3627
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
4264 US Hwy 158
Advance NC 27006 Directions
Structure: SINGLE FAMILY Hwy 158 east, 5th or 6th house near Smith Grove FD
#of Bedrooms: 3
#of People:
*Water Supply: PUBLIC
* Issued by.
*System Classification/Description:
IP
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by: 2140-Nations,Robert
Saprolite System? QYes QNo
Design Flow: 3 6 0GRAVITY-SERIAL Pump Required?
Distribution Type: OYes QNo
Soil Application Rate: 0 2 7 S *Pre Treatment:
Drain field
r
mtion Field 1 3 0 9 Sq-ft. *System Type: INFILTRATOR QUICK4STANDARD
rain Lines 5 Installer: Brian McDaniel
Total Trench Length: 3 1 6 ft. Certification#: 1118
Trench Spacing: — 9 Inches O.C.
• Feet O.C. 'EH S: 2140-Nations,Robert
Trench Width: 3inches
gFeet Date: 0 9 / 0 3 / 2 0 15
Aggregate Depth: inches
Minimum Trench Depth: 3 6
Inches
777 '77N
Minimum Soil Cover. 4Inches Approvat Status
Maximum Trench Depth: 3 6 ® Approved C]. Disapproved
Inches
Maximum Soil Cover,
2 4 Inches
CDP File Number 192787 - 1
Septic Tank County ID Number:
Manufacturer. Lat.
STB: Long: ,
Gallons: Installer.
Date: Certification#:
*EH S:
*Filter Brand:
ST Marker. ❑ Yes ❑ No Date:
Apprcnrat
Reinforced Tank: ❑ Yes ❑ NO
Status
1 Piece Tank: ❑ Yes ❑ No '�❑ Ap�iroved[��Disapproved�'
,. ,
Pump Tank
Manufacturer Installer.
PT: Certification#:
Gallons: THS:
Date: / Date:
RiserSealed ❑ Yes ❑ No
RiserHeght ❑ Yes ❑ No (Min.6 in.) , ApprovalstatuWMs
einforced Tank: El Yes ❑ No
Approved D Disapproved
1 Piece Tank: ❑ Yes ❑ No
Supply line
Pipe Size: inch diameter Installer.
Pipe Length: feet Certification#:
*Schedule: THS:
Pressure Rated ❑ Yes ❑ NO Date:
Approved fittings ❑ Yes ❑ No -'pproval StatusMli-
ved❑ Disapproved
Pump Requirement
Pump Type: Installer.
Dosing Volume: - Gal Certification#:
Draw Down: Inches THS:
"Cheat:
Date:
Valves Accessible ❑ Yes ❑ NO
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve ❑ Yes ❑ NO Approval Status
PVC unions El Yes ❑ No ❑ Approved 0 Disapprovetl
Vent Hole ❑ Yes D No
Anti-siphon Hole ❑ Yes 0 No
CDP File Number 192787 - 1 County ID Number:
Electric Equipment
NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer:
Box 12 inches Above Grade ❑ Yes El No
Box Adj.TYes ❑ N o
To Pump Tank Certification#:
❑
Conduit Sealed ❑ Yes ❑ NO *ENS:
Pump Manually Operable ❑ Yes ❑ NO
*Activation Method: Date:
Approval Status
Alarm Audible ❑ Yes ❑ No [p Approved❑ Disapproved
Alarm Visible ❑ Yes E3No
2140•Nations,Robert
*Operation Permit completed by:
Authorized State A nt: Date of Issue: 0 9 / 0 3 / 2 0 1 5
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 IIk sewage septic system.
Rule.1961 requires that a Type TYPE II A. septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: N/A
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency ByCedified 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 entitywith a certified operatoror a private certified operator forthe life of the septic system.
Rule.1961 requires that Type VI septic systems designed for a 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 Penn it 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 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.
4Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT 1927874- 1
Davie County Health Department CDP File Number:
210 Hospital Street
County File Number:
P.O.Box 848
Mocksville NC 27028 Date:
Q Inch
Scale:
Drawing Drawing Type: Operation Permit . Ok
N A ft.
� M I
1
I
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t
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3
CONSTRUCTION For Office Use Only
AUTHORIZATION *CDP File Number 192787=1
Davie Count Health Department Y P I County ID Number
210 Hospital Street ��LL�D "Z�' Evaluated For REPAIR.
'.� �. P.O. Box'848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 0 4 / a 0 / a 0 a 0
Applicant: Ruby Lyons Property Owner. Ruby Lyons
Address: 4264 US Hwy 158 Address: 4264 US Hwy 158
City: Advance City: Advance
State/Zip: NC 27006 State2ip: NC 27006
Phone#: (336)998-3627 Phone#: (336)998-3627
Property Location & Site Information
Address/Road #: Subdivision: Phase: Lot:
4264 US Hwy 158
Advance NC 27006 Directions �...
Structure: SINGLE FAMILY Hwy 158 east, 5th or 6th house near Smith Grove FD
#of Bedrooms: 3
#of People:
"Water Supply: PUBLIC
System Specifications
Minimum Trench Depth: a 4
rDneisiggnn
sification: Provisionally Suitable Inches
Minimum Soil Cover.
System? OYes @No 1 '2 Inches
w: 3 6 0 Maximum Trench Depth: 3 6 Inches
SoilMaximum Soil Cover:
Application Rate: 0 . 1 3 5 a 4 Inches
*System Classification/Description: *Distribution Type:
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
Gallons
*Proposed System: 250%REDUCTION 1-Piece: OYes ONo
Pump Required: OYes ONo OMay Be Required'
Nitrification Field 1 3 0 9 Sq. ft. PumpTank: Gallons
No.Drain Lines 3 1-Piece: OYes ONo
Total Trench Length: 3 a 7 ft GPM vs— ft. TDH
Trench Spacing: Inches O.C.
9 . @Feet O.C. Dosing Volume: _ Gallons
Trench Width: Q Inches
_ 3 +r Feet Grease Trap:_ _ Gallons
Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-11
Septic Tank InstallerGrade Level Required: 01011 0111 OIV
Pana 4 of Q
i1
CDP File Number 192787- 1 County ID Number.
❑ Open Pump System Sheet
Repair System Required:OYes ONo ONo, but has Available Space
r
rnesign
System Trench Spacing: QInches O. .
ification: — V Feet O.C.
Trench Width: Inches
w: I — _, 0 Feet
SoilApplication Rate: Aggregate Depth: inches
`� • Minimum Trench Depth:
"System Classification/Description: Inches
Minimum Soil Cover. Inches
Maximum Trench Depth:
'Proposed System: Inches
Nitrification Field
Maximum Soil Cover:
Inches
Sq.tit.
No. Drain Lines *Distribution Type:
Tota(Trench Length: �. Pump Required: OYes ONo OMay Be Required
Pre Treatment: ONSF 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 bythe 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 bevalid fora person equal to the period of validity of the improvement Permit,not
to exceed five years,and may be lssued atthe smetime 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 theappllcaUon fora permit or ConsWctton
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 besuspended or revoked(.1937(g)).The person owning or,controlling the system shall be msponsiblefor assuring compliance
with the laws„rLdes,and permit conditions regarding system location,Installation,operation,maintenance;monitoring,reporting and repair
Applicant/Legal Reps.Signature Required? OYes ONO
ApplicanttLegal Reps.Signature: Date:
*Issued By: 2140-Nations,Robert Date of issue: . 0 . 4 _ a 0 2 0 1 5
AutherifffState Agen . '�`'` =--- '""" �"' Malfunction Log OYes
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
• CONSTRUCTION AUTHORIZATION
Davie County Health Department CDP File Number: 192787- 1
210 Hospital Street
P.O. Box 848 County File Number:
Mocksville NC 27028 Date: 0 4 / a 0 / a 0 1 5
Q Inch
Drawing Drawing Type: Construction Authorization Scale: . . QBlock = ft•
QN/A
• cz�j CLj 6 c
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Lat '002 .
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Davie COUNTY
210 Hospital Street
P.O. Box 848
Mocksville NC 27028 TEL: 336-753-6780 FAx: 336-753-1680 Request ID: 55642
REQUEST FOR SERVICE/COMPLAINT INVESTIGATION REPORT
REQUEST DATE: 04/06/2015 TAKEN BY:
SECTION: N/A TYPE:
PROPERTY NUMBER: 192787 ASSIGNED TO: Nations, Robert
ESTABLISHMENT NUMBER:
PERSON OR PREMISES TO SEE: OWNER: Ruby Lyons
Ruby Lyons 4264 US Hwy 158
4264 US Hwy 158 Advance , 27006
Advance NC, 27006
(336) 998-3627
REQUESTED BY: Owner HOME:
WORK:
Cell:
CONDITION REPORTED:Over flowing septic pumped Jan and Dec
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:
DATE: HR/MT: COMMENTS
EHS:
EHS #:
ACT CODE:
Next Inspection Date: Status of Complaint: OPEN Resolved Date:
Complaintant Contacted: NO
DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST
APPLICATION IP/ATC OSWW REPAIR
Name Z&uiL�6n5 Telephone Number &'o DL
Address W)(PLI ICo& AA—Vayy't k4-7,5-
Mailing Address (if different from above) Vol
Email Address:
Subdivision Name Lot#
Directions . re- pas f-`6 yy) S W1��-h Gym 1--7t✓P ri Pot.
Date System Installed i j wS oLch b Name System Installed Under'1-,kWRoVwr-{-
Type Facility xSf- Number Bedrooms Number People Served
Type Water Supp lys
J, o Specific Problem Occurring �-1vji
D to Requested l Info Taken By S
THIS IS TO CERTIFY THAT,THE 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 7
Revisit Charge Date Reason
Revised 2-2011
DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST
`Y APPLICATION1.IP/ATC OSWW REPAIR .
Name _ t i 'i_ Telephone Number
,"Address `, laLl L ( 4 v �:ti �` ;: ',� t {" '�.{� �-� 7 ; w;f ,•,�,
Mailing Address(if different from above)
Email Address:
Subdivision Name. i ,�' Lot#
Directions ", _
Date System Installed Name System Installed Under
Type Facility Number Bedrooms Number People Served
Type Water Supply Specific Problem Occurring
Date Requeste` (; (: 1 Info Taken By
THIS IS TO CERTIFY THAT THE 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
Revisit Charge Date Reason !"!
Revised 2-2011 ":
DEED BOOK 69
STATE OF NORTH CAROLINA-Davie County.
THIS DEED,Made thia. A..........-.day of__ - March A.D.195AL.,
,_ McKinley_Dulina Ja per J. Dulin. Shirley Qtudevent and Henry J. Dulin
qe of Redland Church of Christ
and StateL-N-o r-t-h.-Carolina.,--. ' * of the first part,
Robel;:� onq and wife, Ruby Lyons
OL.- Davie --------County and State of..- North Carolina the second part:
Wn'NESSETH,That the
In consideration of__.EqAnap1Xqrd Fifty and no/100 A
to__th.e.&._pald the receipt of which is hereby acknowledged,ba--XV.-
bargained and sold,and by these presents do grant,sell or convey to
heirs and assigns,a certain lot,tract or parcel of lend iA Davie County,State of North Carolina,adjoining the lands of
...................._...._......._..........and others,bounded as follows,viz:
BEGINNING at an iron Shirley Qtudevent9e comer; thence
N. 74 degs. 45 min. E. 131.4 ft. to an iron Church of
Christ corner (colored); thence N. 15 degs. W. 187 ft.
to the center line.of U. Q. Highway No. 158, Church of
m
Christ corner; thence with said center line of Highway
No.
158 S. 74 deg*. 40 min- W. 131.4 ft. to point in
Road, Shirley atudeventto comer* thence with Shirley
4tudevent's line S. 15 degs. E. 186.5 ft. to the
Nwinning, containing 955 (55/100) acre, more or less,
To HAVE AND TO HOLD the aforesaid tract,lot or parcel of land,and all privileges and appurtenances thereto belonging to the
said and assigns,_t.h.%Jr.._._onIy use and behoof forever.
And the sald_,pa&ias oL.1he-first part........._._.....for.them.sel..Y.9.3..and t4h.81MIrs,executors and administrators,
covenanL—with and assigns,that.111.01 are
seized of said premises In fee,and ha...Y"ht to convey in fee simple;that the same an free and clear from all encumbrances,and
tha&h0Y.do__hereby forever warrant and will forever defend the said title to the same against the claims of all persons whom-
soever—__—____.»...__..... __ _...».—._. _ __ Shirley
hom-
Shirley otudevent and Henry L. Julin,
IN TESTIMONY VJHER] F def _%1li11/ha_Y1._.hecunto set.—I&L'Ar................
r r
s s., . e
a e
hand-a.-and seal..*........,the day and year first above written. .......McKinley QuUn........................__..__....._..........(seal)
Qtudevent ......................_._....(Seal)
Attest: Henrv_L. i)ulin ------_-......................._.(Seal)
STATE OF NORTH CAROLINA,.....................................COUNTY.
1, Clerk of the Superior Court,hereby certify that........................................
.................................................................................................................................................................__...................
personally appeared before me this day and acknowledged the due execution of the annexed deed of conveyance.Let the instrument,
with this certificate,be registered.
Witness my hand and official seal,this................................day of............................................................................A.D.195._......
.»....._.._..—...._.._.........._....._............Clerk Superior Court.
STATE OF NORTH CAROLINA,.......QJlYi1._..._._...._..COUNTy.
I. ........................................................................................Notary Public,do hereby certify that
Mr.K lan.ar ..Eemrff ........................................
personally appeared before me this day and acknowledged the due execution of the annexed deed of conveyance.
Witness my hand and notarial seat this._.—A.................day of .....................................A.D.195._8._
My commission expires_..qSl�_ lia. smith N.P.(Seal)
STATE OF NORTH CAROLINA—DAVIE COUNTY.
The foregoing certificate of..--J.v Re jP_Mith..................................a Notary Public of................AX1.1.................County,
Is adjudged to be correct.Let the same,with this certificate,be registered.
This................_day ........................A.D.195
Witness my hand and official seal,this __4_...____.day of .»......_......__ A.D.193
H2-10aftin............................_Clerk Superior Court.
Filed for registration on the 14..........day .......... A.D. 195.8at.111.49'clock.A.M.,and
registered in the office of the Register of Deeds of Davie County,X.C.,this Aay ....................................
aL9.*.3.0-...o'clock..--..A-.-.M.,In Book..__.59...___of Deeds on page 1*96..............etc.
.............J.2-I't-Amith............................Register of Deeds,
# Page 1 of 1
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• (Latitude:33-0J3' 11.09" Longitude -800 28` 43.94'
http://map,s2.roktech.net/davie gomaps/index.html 4/21/2015
Parcel#:E700000011 Page 1 of 1
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Parcel#:E700000011 Account#:46701500
Owner Information Tax Codes
[264
ONS RUBY ADVLTAX-COUNTY T
US HIGHWAY 158 FIREADVLTAX-FIRE TAXVANCE NC 27006
Property Information Township
nd(Units/Type): 0.380 AC FARMINGTON
ddress:4264 US HWY 158
Deed Information Local tonin
ate: 03/1958 Book: 00059 Page:0496
Plat Book: Page:
Le al Description PIN
131 FF HWY 158 5861277015
Property Values
ulldin : 64,04
BXF:
nd• 15,21
Market: 79 25
eased: 79 25
eferred:
Sales Information
No. Book Paye Month Year Instrument Qual/UnQuai Improved Price
1 00059 0496 03 1958 WD Unqualified improved 0
View Property Record for this Parcel View Map for this Parcel View Tax Bill Information
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All information on this site is prepared for the inventory of real property found within Davie County. All data is compiled from recorded deeds,
plats, and other public records and data. Users of this data are hereby notified that the aforementioned public Information sources should be
consulted for verification of the information. All information contained herein was created for the Davie County's internal use. Davie County,
its employees and agents make no warranty as to the correctness or accuracy of the information set forth on this site whether express or
implied, in fact or in law, Including without limitation the implied warranties of merchantability and fitness for a particular use.
If you have any questions about the data displayed on this website please contact the Davie County Tax Office at(336) 753-6120.
1.5.9
http://maps.daviecountync.gov/itsnet/View.aspx?prid=1471156 6/16/2016