140 Savannah Ct, Lot 17 (2) ' or Ice use Only
OPERATION PERMIT
a� Davie County HealthDepartment 'CDP bite,Num ber 175543-11
210 Hospital Street
P.O. Box 848 County ID Number:
Mocksville; NC 27028 Evaluated For: REPAIR
Phone: 336-753-6780 Fax:336-753-1680 Township:
Applicant: Nicole Jones Property Owner: Nicole Jones
Address: 140 Savannah Court Address: 140 Savannah Court
City: Advance City: Advance
St8te2ip:, NC 27006 State/Zip: NC 27006
Phone#: Phone#:
Property Location & Site Information
Address/Road#: Subdivision: Alton Place Phase: Lot: 17
140 Savannah Ct
Advance NC 27006 Directions
structure: SINGLE FAMILY Hwy 158 East, right on Baltimore Rd. Left on
Beauchamp, then right on Savannah Ct.
#of Bedrooms:
#of People:
'Water Supply: PUBLIC
'IP Issued by: 'System Classification/Description:
TYPE II A COM/SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
'CA issued by: 2140-Nations,Robert Seprolite System? Q Yes @ N o
Design Flow: 4 8 0 "Distribution Type: GRAVITY-SERIAL Pump Required?
QYes 4No
Soil Application Rate: 0 a 7 5 'Pre-Treatment:
Drain field
r
itrification Field Sq. ft. 'System Type:
o. Drain Lines Installer: Randy Miller
Total Trench Length:. ft.
Certification#:
Trench Spacing: (Inches O.C.
Feet O.C. 'EHS: 2140-Nations,Robert
Trench Width: Inches
— ()Feet Date: 1 .2 / 1 5 j 2 0 1 4
Aggregate Depth: inches
Minimum Trench Depth:
Inches
Minimum Soil Cover 's
' R Approval Status
Inches � 1� �A � ,
�-, a � � xr .� m y jai•
Maximum Trench pepth: Inches rj�; yu Al3pro e �lDlsapprove74
Maximum Soil Cover: Inches
-
CDP File Number 175543 1 County ID Number:
Se tic Tank
Manufacturer. Let.
Long:
STB:
Installer:
Gallons:
Date: j j Certification#:
*EH S: 2140-Nations,Robert
*Filter Brand:
ST Marker: ❑ Yes El No Date: 1 x / 1 5 a 0 1 4
j
Reinforced Tank:
❑ Yes
D No' hi�NWNrpiii,�ai '
1 Piece Tank: ❑ .Yes ❑ Na �� ,,� � QQ�Appr�u�tl❑ „D�SapprorCetl���
Pump Tank
Manufacturer. Installer:
PT: Certification#:
Gallons: *EHS:
Date: j j Date: j I
Riser Sealed ❑ Yes ❑ No
RiserHeight: ❑ Yes ❑ No (Min.6 in ).
-
einforced Tank: ❑ Yes ❑ No
HCl ApprovedO D>sapproved
1 Piece Tank: ❑ YeS O No =
Supply Line
T
ize: inch diameter Installer:
gth: feet Certification#:
*Schedule: *ENS:
Pressure Rated ❑ Yes ❑ No Date:
Approved fittings El Yes Na II " ral'Status
r au:in�@ �pp
❑ Approve'd'D plsapproYetlI
P Requirement
Pump Type: Installer:
Dosing Volume: - Gal Certification#:
Draw Down: Inches *EHS:
*Chain: j f
Date:.
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve ❑ Yes ❑ No
Ian Approval ta�us�� � �
an ,
i
PVC Unions ❑ Yes ❑ N4hd� L' '❑ Approved❑ }Disapproved
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole ❑ Yes ❑ No
CDP File Number 175543 - 1 County ID Number:
Electric Equipment
N�EMA Box or Equivalent ❑ Yes ❑ No Installer
Bax 12 inches Above Grade ❑ YeS ❑ No
Certification#:
Box Adj.To Pump Tank ❑ Yes ❑ No
Conduit Sealed ❑ Yes ❑ No *BHS:
Pump Manually Operable ❑ Yes ❑ Na
*Activation Method: Date: I I
i
Alarm Audible ElYes ElNo _ � Approval Status
M❑i Approved❑' Disapproved L
Alarm Visible ❑ Yes ❑ No ON
2140-Nations,Robert
*Operation Permit completed by:
Authorized State Agent: OF Date of Issue: 1 2 I 1 5 I 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.,end all conditions,of the Improvement Permit and
Construction Authorization.This property is served by a TYPE it A sewage Si?ptlC System.
Rule .1961 requires that a Type TYPE ti A• septic system meet the following criteria:
Minimum System Review By The local Health Department: NIA
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency By Certified Operator:
N/A
Reporting Frequency By Certified Operator: NIA _
Rule .1961 requires that a Type IV and V septic systems designed .fora homelbusiness owner must maintain a valid contract
With a public management entitywith a'certified operatoror 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 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 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 ,a
**Site Plan/Drawing attached.*
OPERATION PERMIT 175543 - 1
Davie County Health Department CDP File Number:
210 Hospital Street
P.O.sox 848 County File Number:
Mocksville IVC 27028 Date:
Q Inch
Drawing Drawing Type: Operation Permit Scale: . QBlock
t
' k
C
E
I
.CONSTRUCTION For office use Oniy
AUTHORIZATION 'CDP File Number 175543-1
= Davie County Health Department County ID Number.
( 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 1 1 / a 5 / a 0 1 9
Applicant: Nicole Jones Property Owner: Nicole Jones
Address: 140 Savannah Court Address: 140 Savannah Court
CRY: Advance CRY: Advance
State2ip: NC 27006 State2ip: NC 27006
Phone#: Phone—:
Property Location & Site Information
Address/Road#: Subdivision: Alton Place Phase: Lot: 17
140 Savannah Ct
Advance NC 27006 Directions
Structure: SINGLE FAMILY Hwy 158 East, right on Baltimore Rd. Left on Beauchamp,
then right on Savannah Ct.
#of Bedrooms:
#of People:
'Water Supply: PUBLIC
System Specifications
CFlowMinimum Trench Depth: a 4
:
Provisionally Suitable Inches
Minimum Soil Cover.
OYes QNo 1 a Inches
4 8 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.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
_ Gallons
'Proposed System: 25%REDUCTION 1-Piece: OYes ONo
Pump Required: OYes ONo OMay Be Required
Nitrification Field 1 4 5
Sq. ft. Pump Tank: Gallons
No. Drain Lines 1-Piece: OYes ONo
Total Trench Length: 1 0 9 ft GPM—vs— ft. TDH
Trench Spacing: 9 Inches O.C. Dosing Volume: _ Gallons
Feet O.C. g
Trench Width:
— 3 . @Inches,
Feet Grease Trap: Gallons
Aggregate Depth:
inches Pre-Treatment: ONSF OTS-1 OTS-II
Septic Tank InstallerGrade Level Required: OI OII OIII OIV
Pagel of 3
CDP File Number 1.75543•- 1 County ID Number:
• ❑ Open Pump System Sheet
Repair System Required:OYes ONo ONo, but has Available Space
rDesign
System
Trench Spacing: Inches O.C.
Classification: — Feet O.C.
Trench Width: Q Inches
w: — 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 Inches
Sq. ft.
No. Drain Lines Distribution Type:
Total Trench Length: ftPump Required: QYes ONo OMay Be Required
Pre Treatment: ONSF OTS-1 OTS-11
"Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. q•
7
"Permit Conditions
The issuance of this permit by the Health Department in no way guarantees the issuance of other permits.The permit holder CA
is responsible for checking with appropriate governing bodies in meeting their requirements.
2
This Authorization for Wastewater System Construction shall bevalid for a person equal to the period of validity of the improvement Permit,not
to exceed five years,and may be issued at the sametime the Improvement Permit Issued(NCGS 130A-336(b)).If the installation has not been
completed during the period of valldity 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 besuspended 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? Oyes ONO
Applicant/Legal Reps. Signature: __Date:_
'Issued By: 2140-Nations,Robert Date of Issue: 1 1 / 2 5 / 2 9 1 4
Authorized State Agent:
:7- Malfunction Log Oyes
OHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION 175543 - 1
Davie County Health Department CDP File Number:
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 1 1 / 2 5 / 2 0 1 4
Qlnch
Drawing Drawing Type: Construction Authorization Scale: ' 013lo k ft.
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