3090 Hwy 64EOPERATION PERMIT
p Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753.6780 Fax: 336-753-1680
Applicant: Rebecca Lewis
Address: 3090 US Hwy 64 East
Cdy: Mocksville
State/Zip: NC 27028
Phone #: (336) 940-2146
Address/Road #: Subdivision:
3090 US Hwy 64 East
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 2
# of People:
*Water Supply: EXISTING WELL
*IP Issued by. 2140 -Nations, Robert
*CA issued by: 2140. Nations, Robert
Design Flow: 2 4 0
Soil Application Rate: 0 a 7 5
Nitrification Field
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Aggregate Depth:
8
,/'Property Owner. Rebecca Lewis
Address: 3090 US Hwy 64 East
CRy: Mocksville
State/Zip: NC 27028
hone #: (336) 940-2146
n
Phase: Lot:
Directions
Hwy, 64 East on right across from Keith Restoration
Cars
*System Classification/Description:
'TYPE 11 A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
SaproliteSystem? ( Yes ONo
*Distribution Type: GRAVITY • SERIAL Pump Required?
QYes @No
*Pre Treatment:
Drain field
8 7 2 Sq. It.
a
2 1 6 �.
9 Inches O.C.
Feet O.C.
3 Inches
Feet
inches
*System Type: INFILTRATOR QUICK 4 STANDARD
Installer: Brina McDaniel
Certification #: 1118
*EH S: 2140 - Nations, Robert
Date. 0 3/ 0 8/ 2 0 1 6
Minimum Trench Depth: 3 6
Inches
Minimum Soil Cover. 4
Inches
Maximum Trench Depth: 4 8 Inches C
Maximum Soil Cover. 3 6 Inches
CDP File Number 137711 -1
Manufacturer.
STB:
PT:
Gallons:
Date:
/
Date:
Yes
RiserHeight: ❑
Yes
*FilterBrand:
1 Piece Tank: ❑
Yes
ST Marker.
❑ Yes
❑
No
nforced Tank:
❑ Yes
❑
No
1 Piece Tank:
❑ Yes
❑
NO
Manufacturer
PT:
Gallons:
Date:
/
RiserSealed ❑
Yes
RiserHeight: ❑
Yes
Reinforced Tank: ElYes
1 Piece Tank: ❑
Yes
County ID Number: .n'120-Aa029,. +14
Lat.
Long:
Installer
Certification #:
*EHS:
Date: / /
Pump Tank
Installer
Certification #:
*EHS:
/ Date:
❑ No
❑ NO (Min.6 in.) Approval Status ��
❑ No
❑ Approved ❑ Disapproved
❑ No
Sunnly Line
Pipe Size: inch diameter
Pipe Length: feet
*Schedule:
Pressure Rated ❑ Yes ❑ No
Approved fittings ❑ Yes ❑ No
Installer
Certification #:
*EHS:
Date:
/ Pump Type:
/
Installer.
Dosing Volume:
—
Gal Certification 9:
Draw Down:
Inches
"EHS:
*Chan:
Date:
Valves Accessible
❑ Yes
❑
No
Flow Adjustment Valve
❑ Yes
❑
NO
Check -valve
❑ Yes
❑
No
Approval Status
PVC unions
ElYes
❑
No
ElApproved
1:1 Disapproved
Vent Hole
❑ Yes
❑
No
Anti -siphon Hole
❑ Yes
0
No
CDP File Number 137711 -1
Electric Equipment
County ID Number: J7 -120-A°-029
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:
Approval Status
Alarm Audible El Yes C3 No -
Approved ❑ Disapproved
Alarm Visible ❑ Yes ❑ No
2140 • Nations, Robert
*Operation Permit completed by.
Authorized State Age " , ..;f,c�.�---�_.--- --�. Date of Issue: 0 3 / 0 8 1 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 11 A. septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: WA
Management Entity: OWNER
Minimum System InspectionlMaintenance Frequency ByCedified Operator.
WA
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 entity with 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 operatorforthe 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 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. R shalt also be a condtion of
the Operation Permit that subsequent owners of the systems execute such a contract.
@Hand Drawing OlmportDrawing
**Site Plan/Drawing attached.**
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC
Drawing Drawing Type: Operation Permit
CDP File Number: 137711
County File Number: J7 -120 -AO -029
27028 Date:
Q Inch
Scale: pBlock
QN/A
ENO
WE
NMI
MEN
No
No
a,
E
No
0
No
Applicant:
Address:
City:
State/Zip:
Phone #:
CONSTRUCTION
AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Rebecca Lewis
3090 US Hwy 64 East
Mocksville
NC 27028
(336) 940-2146
Location
Address/Road #: Subdivision:
3090 US Hwy 64 East
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 2
# of People:
*Water Supply: EXISTING WELL
/ For Office Use Only
*CDP File Number 137711 - 1 ��•
County ID Number: J7 -120-A0-029
Evaluated For: REPAIR
Township:
PERMIT VALID UNTIL:
0 4/ a 9/ a 0 1 9
Property Owner: Rebecca Lewis
Address: 3090 US Hwy 64 East
City: Mocksville
State/Zip: NC 27028
Phone #: (336) 940-2146
Phase: Lot:
Directions
Hwy 64 East on right across from Keith Restoration Cars
Classification:
Provisionally Suitable
Minimum Trench Depth:
a 4 Inches
\Site
Saprolite System?
O Yes (gNo
Minimum Soil Cover:
1 a Inches
Design Flow:
a 4 0
Maximum Trench Depth:
3 6 Inches
Soil Application Rate:
0 x 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:
O Yes O No
Pump Required: O Yes
O No O May Be Required
Nitrification Field
8
7
a
Sq. ft. Pump Tank:
Gallons
No. Drain Lines
3
1 -Piece:
OYes ONo
Total Trench Length:
a 1 8
GPM --vs— ft. TDH
ft
Trench Spacing:Inches
—
9
O.C.
Feet O.C. Dosing Volume:
_ Gallons
Trench Width:
3
Inches
Feet
_
Grease Trap:
Gallons
Aggregate Depth:
inches
Pre -Treatment: O NSF OTS -I O TS -II
Septic Tank Installer Grade Level Required: 01011
OIII ON /
Page 1 of 3
Cl-' File Number 137711 - 1
r Svstem
*Site Classification:
Design Flow:
Soil Application Rate:
*System Classification/Description:
*Proposed System:
Nitrification Field
No. Drain Lines
Total Trench Length:
ft.
County ID Number: J7 -120 -AO -029
❑ Open Pump System Sheet
OYes O No ONo. but has Available S
Trench Spacing: _ O Inches O.
O Feet O.C.
Trench Width: Inches
8Feet
Aggregate Depth:
inches
Minimum Trench Depth:
Inches
Minimum Soil Cover:
Inches
Maximum Trench Depth:
Inches
Maximum Soil Cover:
Inches
Sq. ft.
*Distribution Type:
Pump Required: Oyes
O No O May Be Required
Pre -Treatment: O NSF
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. =--g-
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. Rmafning
Rm.fn°"
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(8)). 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 - Nations, Ro ert Date of Issue: 0 4 / .2 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
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Construction Authorization
CDP File Number: 137711 - 1
County File Number: J7 -120 -AO -029
Date: 04/.29 /,2014
O Inch
Scale: O Block
O N/A
Page 3 of 3
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Z
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
CDP File Number: 137711 - 1
County File Number: J7 -120 -AO -029
Date: A4./ 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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