2483 Hwy 601S OPERATION PERMIT EFor
e ny
Davie County Health Department 136703- 1
;J
210 Hospital Street 1.5-1140-Ao-oo6
P.O. Box 848
Mocksville NC 27028 AIRPhone:336-753-6780 Fax:336-753-1680
Applicant: Brian Nichols rAd
erty owner Brian Nichols
Address: ress:
City: City:
StatefZip: NC State0p: NC
Phone#: Phone#:
Property Location & Site Information
r
dress/Road #: Subdivision: Phase: Lot:
2483 US Hwy 601 South
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 601 south pass Fairfield, pass on Service
station on right. then a car lot on left, house on left
of Bedrooms: 3 before Intersection at Hwy 801.
#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: 21140-Nations,Robert
v Saprolite System? OYes ANo
Design Flow: 3 6 0 * GRAVITY-SERIAL Pump Required?
Distribution Type: O Yes CENo
Soil Application Rate: 0 - a 7 5 *Pre Treatment:
Drain field
rNkrnifimtion Field 1 3 0 9 Sq•n• *System Type:in Lines 3 Installer: Randy Miller
Total Trench Length: 3 a 7 ft. Certification#: 11128
Trench Spacing: — 9 Inches O.C.
Feet O.C. *EH S: 2140-Nations,Robert
Trench Width: 3 Inches
&Feet Date: 0 6 / 1 7 J 2 0 1 5
Aggregate Depth: inches
Minimum Trench Depth: 3 6
Inches
Minimum Soil Cover. a 4Inches -ApprovalStatus`�
Maximum Trench Depth: 3 6 ® Appra,vedlO Disapproved: ,
Inches
Maximum Soil Cover:
2 4 Inches
CDP File Number 136703 - 1 Septic Tank County ID Number: -Sao-Aa006 s
Manufacturer. Let:
Long:
STB: -
Gallons: Installer.
Date: Certification#:
*EHS:
*Filter Brand:
ST Marker ❑ Yes ETNo Date:
Reinforced Tank: ❑ Yes ❑ No _
Approval Status
1 Piece Tank: O Yes ❑ No �❑ Approved❑_, Disapproved,s
�e
Pump Tank
Manufacturer. Installer:
PT: Certification#:
Gallons: *EHS:
Date: Date:
RiserSealed ❑ Yes ❑ Na
RiserHeight: ElYes O No (Min.6 in.)
Approval Status
Reinforced Tank: ❑ Yes E No -�❑ Aroved❑�Dtsa
proved
1 Piece Tank: ❑ Yes El No PP PP
Supply Line
CPipe Size: inch diameter Installer,
Pipe Length: feet Certification#:
*Schedule: *EHS:
Pressure Rated ❑ Yes ❑ No Date:
Approved fittings ❑ Yes ❑ No Approval Status
�❑ Approved❑ Disapproved
f
Pump RequiEemenj
CDosing
p Type: Installer:
Volume: — G.I Certification#:
w Down: Inches *EHS:
"Chau:
Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve ❑ Yes ❑ NO Approval;,Status
PVC unions ❑ Yes ❑ No O Approved❑ Disapproved
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole El Yes ❑ No
CDP Nle Number 136703 - 1 County ID Number: I-s'140-ao-006
Electric Equipment
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 Manually Operable ❑ Yes ❑ No
*Activation Method: Date: /
ApprovalStafus -
Alarm Audible ❑ Yes ❑ No
proved❑ Disapproved
Alarm Visible ❑ �es ❑�Wo
2140•Nations,Robert
'Operation Permit completed by:
Authorized State Agent: Date of Issue. 6 / 1 7 / a 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.I8A.1900 et. Seq.,and all conditions of the Improvement Permit and
Construction Authorization.This property is served by a TYPE 11 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 ByCertified Operator:
N/A
Reporting Frequency By Certified Operator. NIA
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 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 for maintenance and
operation, responsibilities of the ownerand 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 condKion of
the Operation Permit that subsequent owners of the systems execute such a contract.
OHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT 136703 - 1 ,
Davie County Health Department CDP File Number:
210 Hospital Street 1.5-140•AO-006
P.O.Box 848 County File Number:
Mocksvilie NC 27028 Date:
Q Inch
Drawing Drawing Type: Operation Permit Scale. . ON A k
19
1 F i
IN
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CONSTRUCT9ON For Office Use Only
AUTHORIZA110M *CDP File Number 136703- 1
Davie County Health Department County ID Number: L5-140-AO-006
210 Hospital Street Pi led L11 '� j1
"l Evaluated For. REPAIR
P.O. Box 848 Township:
Mocksville NC 27028 PER6itT VALID UNTIL:
Phone: 336-753-6780 Fax:336-753-1680 0 4 / 1 0 / .2 0 1 9
Applicant: Brian Nichols Property Owner: Brian Nichols
Address: Address:
City: CRY:
State/Zip: NC State2ip: NC
Phone#: Phone#:
Property Locatation
rAddress[Road#: Subdivision: Phase: Lot:
3 US Hwy 601 South
ksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 601 south pass Fairfield, pass on Service station on
right. then a car lot on left, house on left before
#of Bedrooms: 3 Intersection at Hwy 801.
#of People:
'Water Supply: PUBLIC
System Specifications
Minimum Trench Depth: a 4
rDesign
sification: Provisionally Suitable Inches
Minimum Soil Cover.
System? OYes QNo 1 a Inches
ow: 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-SERIAL
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
_ _ Gallons
*Proposed System: 25%REDUCTION 1-Piece: OYes ONo
Pump Required: OYes @No OMay 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 ft. GPM—vs— ft. TDH
Trench Spacing: 9 C)Inches O.C. Dosing Volume: _ Gallons
_ * Feet O.C. g
Trench Width:
3 _ 8inches
Feet Grease Trap: Gallons
Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-11
Septic Tank Installer Grade Level Required: 01011 0111 OIV
CDP File Number 136703 - 1 County ID Number: L5-140-Ao-006
❑ Open Pump System She(
Repair System Required:OYes ONO ONO, but has Available Space
rDesign
System
Trench Spacing: Q Inches 0. .
ification: — O Feet O.C.
Trench Width: Inches
w: 8Feet
Soil Application Rate: Aggregate Depth: inches
*System Classification/Description: Minimum Trench Depth: Inches
Minimum Soil Cover.
Inches
Maximum Trench Depth:
'Proposed System: Inches
Maximum Soil Cover:
Nitrification Field Sq. ft Inches
No. Drain Lines
'Distribution Type:
Total Trench Length: Pump Required: OYes ONo OMay Be Required
it.
Pre Treatment: ONSF OTS-1 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 bo valid fora person equal to tho period of validity of the improvement Permit not
to exceed five years,and may be Issued at the sametime the Improwncrit Permit Issued(NCGS 130A-33S(b)}If the instaliation has not been
completed during the period of wlidity of the Construction Permit,the information submitted in the application fora permit or Construction
Authorization Is found to have been incorrec%falsified or changed,or the site is altered,the perrnit or Construction Authorization shall become
Inwlid,and may be suspended or revoked(.1937(g)).The person awning or controlling the system shall be responsible for assuring compliance
with the laws,rules,and permit conditions regarding system location,installation,operation,maentcnance,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 4 / 1 0 / 2 0 1 4
Authorized State Agent:^`'' .� d%6 Malfunction Log OYeS
@Hand Drawing Olmport Drawing
"Site PIT/Drawing attached."
CONSTRUCTION AUTI-IORIZATION 136703 - 1
Davie County Health Department CDP File Number:
• 210 Hospital Street
County File Number: L5-140-AO-006
P.O. Box 848
Mocksville NC 27028 Date: 04 / 1 0 / 2 0 1 4
Olnch
Drawing Drawing Type: Construction Authorization Scale: . OBlock =
ON/A
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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: 46532
REQUEST FOR SERVICE/COMPLAINT INVESTIGATION REPORT
REQUEST DATE: 03/10/2014 TAKEN BY: Brittany
SECTION: N/A TYPE:
PROPERTY NUMBER: 136703 ASSIGNED TO: Nations, Robert
ESTABLISHMENT NUMBER:
PERSON OR PREMISES TO SEE: OWNER: Brian Nichols
Brian Nichols
2483 US Hwy 601 South
Mocksville NC, 27028
q�- �75�
REQUESTED BY: Owner HOME:
WORK:
Cell:
CONDITION REPORTED:Water surfacing on top of ground from septic field. Black sludge
COMMENTS:
RECORD OF INVESTIGATION
DATE: HR/MT: COMMENTS
EHS: C-41t S'-ao-r-A -+%'At es b J Xd ore- Hm G
EHS #:
ACT CODE: OCIVI.C✓ G!t V`•PC�c �'i° ' CSC q—to—I q 55
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 SECTION C0R/1ljC7orC-
tAPPLICATION FOR IMPROVEMENT PERMIT(REPAIR) �d+09
NAME 6Y PHONE NUMBER , „n- 9111 - 77��
ADDRESS Z y�F 1 l�/�l �/V�'1 V� SUBDIVISION NAME
LOT# 0 41%Ar
DIRECTIONS TO SITE
al &A(' P-
DATE SYSTEM INSTALLED Lilk NAME SYSTEM INSTALLED UNDER
TYPE FACILITY 4_� NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
W(A -cN tiUildi--101 (A'b em 4-6o B4` arr/bLf id,- "block- <sltcc�� !�
DATE REQUESTED INFORMATION TAKEN BY
This is to oertify that the information provided is correct to the best of my knowledge,and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1193