575 Howardtown Rd OPERATION PERMIT F*CDPFileNumber
ice use Only
ren.
Davie County Health Department 137630-1
210 Hospital Street G7-ooa-oo-o02-01
P.O. Box 848 mber:
Mocksville NC 27028 Evaluated For: REPAIR
Phone:336-753-6780 Fax:336-753-1680 Township:
Applicant: McMahan Septic Property Owner: Federal Home Loan and
Address: Address:
City: Lexington City:
State/Zip: NC 27295 StatefZip:
Phone#: (336)248-6575 Phone#:
Property Location & Site Information
#StrucElmr.l
Subdivision: Phase: Lot:
Road
NC 27 28 Directions
- H 64 East, turn left on Comatzer Rd. then Left on
E FAMILY
Howardtown Rd. poperty on right.
#of Bedrooms: 3
#of People:
*Water Supply: NIA
*IP Issued by. 2140-Nations,Robert 'System Classification/Description:
*CA issued by: 2140-Nations.Robert
Saprolite System? OYes QNo
Design Flow: 3 6 0 * Pump Required?
Distribution Type: OYes QNo
Soil Application Rate: 0 . 2 7 5 *Pre Treatment:
Drain field
F
on Field 1 3 0 9 Sq•ft- *System Type: FZFLOw EZ 1003T
Lines 3 Installer: McMahan Septic
Total Trench Length: 3 0 0 fl- Certification#: 1120
Trench Spacing: — 9 Inches O.C.
Feet O.C. *EH S: 2140-Nations.Robert
Trench Width: 3Inches
gFeet Date: 0 5 / 1 3 / a 0 1 4
Aggregate Depth: 1 2 inches
Minimum Trench Depth: 3 6
Inches
Minimum Soil Cover. 2 4 Inches Approval Status
Maximum Trench Depth: 3 6 Inches FEI proved O Disapproved
Maximum Soil Cover: 2 4 Inches
• CDP File Number 137630 - 1 Septic Tank County ID Number: G7-000-00-002-01
Lat
Sh•oaf .
Manufacturer. : -
STB: 760 Long -
Gallons:
1000 Installer: McMahan Septic
Certification#: 1120
Date: 0 a / 1 0 / x 0 1 4
'EHS: 2140-Nations,Robert
"Filter Brand: TUF-TITS Dual EF-4
ST Marker: El Yes 0 NO
Date: 0 5 / 1 3 / x 0 1 4
Reinforced Tank: ❑ YeS El NO
Approval Status
1 Piece Tank: ❑ Yes l No O Approved❑ Disapproved
Pump Tank
Manufacturer. Installer:
PT: Certification#:
Gallons: 'EHS:
Date: / / Date:
RiserSealed ❑ Yes ❑ No
RiserHeght: ❑ Yes ❑ NO (Min.6 in.) Approval Status
Reinforced Tank: ❑ Yes ❑ No ❑ Approved❑ Disapproved
1 Piece Tank: ❑ Yes ❑ NO
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
Pump Requirement
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 ❑ Yes ❑ No ❑ Approved❑ Disapproved
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole ❑ Yes ❑ NO
CDP File Number 137630 - 1 County ID Number: G7-000-00-002-0'
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 *EH S:
Pump Manually Operable ❑ Yes ❑ No
*Activation Method: Date:
Approval Status
Alarm Audible El Yes E3No ❑ Approved❑ Disapproved
Alarm Visible El Yes ElNO
2140-Nations,Robert
*Operation Permit completed by: �/
Authorized State Agent: �/ Oate of Issue: 0 5 / 1 5 / a 0 1 4
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 sewage septic system.
Rule .1961 requires that a Type septic system meet the following criteria:
Minimum System Review By The Local Health Department:
Management Entity:
Minimum System Inspection/Maintenance Frequency By Certified Operator:
Reporting Frequency By Certified Operator:
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 priorto 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 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 Olmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT 137630 - 1
Davie County Health Department CDP File Number:
Hospital ospital Street
210 Ho x 8a8 County File Number: c7-000-00-002-01
P.OMocksville NC 27028 Date:
Olnch
Drawing Drawing Type: Operation Permit Scale: . OBlock
ON/A
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• V CONSTRUCTION For Office Use Only
AUTHORIZATION *CDP File Number 137630-1
Davie County Health Department County ID Number. G7-000-00-002-01
210 Hospital Street 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 9 / a 0 1 9
Applicant: McMahan Septic Property Owner. Federal Home Loan and Mortgage
Address: Address:
City: Lexington City:
State/Zip: NC 27295 State/Zip:
Phone#: (336)248-6575 Phone#:
—) ��
Property Location &Site Information
Address/Road#: Subdivision: Phase: Lot:
575 Howardtown Road
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 64 East, turn left on Comatzer Rd.then Left on
Howardtown Rd. poperty on right.
#of Bedrooms: 3
#of People:
*Water Supply: N/A
System Specifications
Minimum Trench Depth: a 4
KSaprolite
lassification: Provisionally Suitable Inches
Minimum Soil Cover. 1 a
System? OYes (&No Inches
Design Flow: 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: 1 0 0 0
Gallons
*Proposed System: 25%REDUCTION 1-Piece: O Yes ®No
Pump Required: O Yes O No O May Be Required
Nitrification Field
Sq.ft. Pump Tank: Gallons
No. Drain Lines 1 1-Piece: OYes ONo
Total Trench Length: 1 0 9 ft GPM vs— ft. TDH
Trench Spacing: _ 9 Inches O.C.
Feet O.C. Dosing Volume: Gallons
Trench Width: 3 Inches
Feet Grease Trap: Gallons
Aggregate Depth:
inches Pre-Treatment: O NSF OTS-1 OTS-II
Septic Tank Installer Grade Level Required: 01011 O III ON
Page 1 of 3
CDP File Number 137630 - 1 County ID Number: G7-000-00-002-01
❑ Open Pump System Sheet
Repair System Required:0 Yes ONO ONO, but has Available Space
Repair System
Trench Spacing: Inches O. .
*Site Classification: Feet O.C.
Trench Width: Inches
Design Flow: 0 Feet
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 Inches
Sq.ft.
No. Drain Lines *Distribution Type:
1 Total Trench Length: ft Pump Required: Oyes 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. a m.�'e
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. Ramm;�g
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 130A336(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(A 937(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? Oyes ONO
Applicant/Legal Reps. Signature- Date:
*Issued By: 2140-Nation Robert Date of Issue: 0 4 / a 9 / a 0 1 4
10,
Ir F
Authorized State Agent. Malfunction Log OYes
®Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
to '
OPERATION PERMIT ice se n v7-771
ate • Davie County Health Department *CDP File Number 137630-1
w 210 Hospital StreetG7-000-00-002-01
P.O. Box 848 County ID Number:
Mocksville NC 27028 Evaluated For: .REPAIR
Phone:336-753-6780 Fax:336-753-1680 Township`.
Applicant: McMahan Septic Property Owner: Federal Home Loan and
Address: Address:
City: Lexington City:
State/Zip: NC 27295 State/Zip:
Phone#: (336)�2575 Phone#:
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
575 Howardtown Road
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 64 East, turn left on Cornatzer Rd. then Left on
#of Bedrooms: 3
Howardtown Rd. poperty on right.
#of People:
*Water Supply: N/A
*IP Issued by: 2140-Nations,Robert *System Classification/Description:
*CA issued by: 2140-Nations,Robert
Saprolite System? O Yes (9 No
Design Flow: 3 6 0 *Distribution Type: Pump Required?
Q Yes (9 No
Soil Application Rate: 0 2 7 5 *Pre-Treatment:
Drain field
r
trification Field 1 3 0 9 Sq•ft. *System Type: EZFLow EZ 1003T
. Drain Lines 3 McMahan Septic
Installer:
tal Trench Length: 3 0 0 ft. Certification#: 1120
Trench S acin OInches O.C.
p g' — g ®Feet O.C. EHS: 2140-Nations,Robert
Trench Width: 3 Inches
—
Feet Date: 0 5 / 1 3 / 0 1 4
Aggregate Depth: ] a inches
Minimum Trench Depth: 3 6 Inches
Minimum Soil Cover: 02 4 Inches pproval Status,„ r
Maximum Trench Depth: 3 6 ®��Approved D�Dlsappro�/ed '-
Inches
Maximum Soil Cover: a 4
Inches ;
Page 1 of 4
' 137630 - 1
CDP File Number Septic Tank County ID Number:
Manufacturer: Sh•oaf Lat.
STB: 760 Long:
Gallons:
1000 Installer: McMahan Septic
Certification#: 1120
Date: QJ a / 1 0 / a 0 1 4
*EHS: 2140-Nations,Robert
*Filter Brand: TUF-TITE Dual EF-4
ST Marker: ❑ Yes ® No Date: 0 5 / 1 3 / x 0 1 4
Approval Status � �
Reinforced Tank: El Yes ® NOS �� �
' ®�Appraued D, DlsaproVed
1 Piece Tank: ❑ Yes ® NO ��ds t
Pump Tank
Manufacturer: Installer:
PT: Certification#:
Gallons: *EHS:
Date: / / Date:
Riser Sealed ❑ Yes D No
Riser Height: El Yes ❑ NO (Min.6 in.) r
AppovaI Status ��
Reinforced Tank: [:1 Yes D No
D Approved JDlsapprov � ,�
1 Piece Tank: ❑ Yes D NO �
Supply Line
Pipe Size: inch diameter Installer:
Pipe Length: feet Certification#:
*Schedule: *EHS:
Pressure Rated ❑ Yes D No Date:
Approved fittings ❑ Yes ❑ NO A
pp Sta
"rovai tus � I
s
3' ❑,Approved❑ :Disapproved" „
Pump Requirement
Pump Type: Installer:
Dosing Volume: - Gal Certification#:
Draw Down: Inches *EHS:
*Chain:
Date:
Valves Accessible ❑ Yes D NO
Flow Adjustment Valve ❑ Yes D No
Check-valve ❑ Yes D NO �111i1111 3Aproval Status e
PVC Unions ❑ Yes D No
Q, Approved D,,.Disapproved ,..,,....
Vent Hole D Yes D NO . ..
Anti-siphon Hole ❑ Yes D NO
Page 2 of 4
t
CDP File Number 137630 - 1 County ID Number: G7-000-00-002-01
Electric E ui ment
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:
y Approval Status
Alarm Audible
El Yes ❑ NO
❑ Apiproved �dI pproved �
Alarm Visible ❑ Yes ❑ NO s �
2140-Nations,Robert
*Operation Permit completed by:
Authorized State Agent: Date of Issue: 0 5 / 1 5 / 2 0 1 4
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 sewage septic system.
Rule.1961 requires that a Type septic system meet the following criteria:
Minimum System Review By The Local Health Department:
Management Entity:
Minimum System Inspection/Maintenance Frequency By Certified Operator:
Reporting Frequency By Certified Operator:
Rule.1961 requires that a Type IV and V septic systems designed for a 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 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 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 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.
®Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 3 of 4
` System Final Inspection Log:
Drain Field: Chamdm
Remaining
750
Septic Tank:
Pump Tank:
Supply Line:
Pump Requirements:
Electrical Equipment:
P1 P2 P3
CONSTRUCTION �� ` For office use only .
AUTHORIZATION '�""""' *CDP File Number;.,137630 1
Davie County Health Department �\ County ID Number G7-000-00-,002-01_
210 Hospital Street Evaluated For:, REPAIR
P.O. Box 848
•+w„.w• Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 0 4 / a 9 a 0 1 9
Applicant: McMahan SepticProperty Owner: Federal Home Loan and Mortgage
Address: 7 Address:
City: Lexington City:
State/Zip: NC 27295 State/Zip:
�'_Pho�ne#. (336)248-6575 Phone#:
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
575 Howardtown Road
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 64 East, turn left on Cornatzer Rd.then Left on
Howardtown Rd. poperty on right.
#of Bedrooms: 3
#of People:
*Water Supply: N/A
System Specifications
Minimum Trench Depth: a 4
(Design
ssification: Provisionally suitable Inches
Minimum Soil Cover:
e System? OYes 43�No 1 a Inches
low: 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:
1 0 0 0 Gallons
*Proposed System: 25%REDUCTION 1-Piece: OYes ®No
Pump Required: OYes 0 N O May Be Required
Nitrification Field
Sq.ft. Pump Tank: Gallons
No. Drain Lines 1 1-Piece: OYes ONo
Total Trench Length: 1 0 9 ft GPM--vs-- ft. TDH
Trench Spacing: Olnches O.C.
9 ®Feet O.C. Dosing Volume: Gallons
Trench Width: _ 3 Olnches
®Feet Grease Trap: Gallons
Aggregate Depth:
inches Pre-Treatment: O NSF OTS-1 OTS-II
Septic Tank Installer Grade Level Required: 01011 O III ON
Page 1 of 3
CDP File Number 137630- 1 County ID Number: G7-000-00-002-01
❑ Open Pump System Sheet
Repair System Required:0 Yes O No O No, but has Available Space
Repair System
Trench Spacing: O Inches O.C.
*Site Classification: — O Feet O.C.
Trench Width: O Inches
Design Flow: _ O Feet
Soil Application Rate: Aggregate Depth: inches
.� Minimum Trench Depth:
*System Classification/Description: 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: ft Pump Required: OYes ONo OMay Be Required
Pre-Treatment: O NSF OTS-I OTS-II
"1-)
*Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. Characters
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. 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-Nation Robert Date of Issue: 0 4 / a 9 / .2 0 1 4
Authorized State Agent: Malfunction Log Oyes
Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION 137630 — 1
Davie County Health Department CDP File Number:
210 Hospital Street G7-000-00-002-01
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 04 / a9 / .10 1 4
0 Inch
Drawing Drawing Type: Construction Authorization Scale: . OO NSA Block
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Page 3 of 3
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CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street CDP File Number: 137630 - 1
P.O.Box 848 G7-000-00-002-01
Mocksville NC 27028 County File Number:
Date: .0.4./.a.9./ a 0 14
Click below to import an image from an external location: Drawing Type: Construction Authorization
Page 3 of 3
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CONSTRUCTION AUTHORIZATION 137630 - 1
Davie County Health Department CDP File Number:
210 Hospital Street G7-000-00-002-01
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 04 / ,29 / a014
Q Inch
Drawing Drawing Type: Construction Authorization Scale' . 00 N/ABlock ft.
6 .t'
413
0 IN
ric
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_.Page 3 of 3
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