2660 Hwy 64WOPERATION PERMIT
s„ Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville ' NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Nathan Singleton
Address: 2660 US Hwy 64 West
City: Mocksville
State/Zip: NC 27028
Phone #: (336) 492-2101
Property Owner Nathan Singleton
Address: 2660 US Hwy 64 West
Cky: Mocksville
State2ip: NC 27028
11Phone #: (336) 492-2101
Property Location & Site Information
Address/Road #: Subdivision: Phase: Lot:
*IP Issued by 2140 -Nations, Robert
*CA issued by: 2140 -Nations, Robert
Design Flow: 3 6 0
Soil Application Rate: 0 a 7 5
Nitrification Field
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Aggregate Depth:
Directions
Hwy 64 West, Pass Vanzant Rd on the left, continue _
about 40 feet home on the right
*System Classification/Description:
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
Seprolite System? OYes QNo
*Distribution T GRAVITY- SERIAL Pump Required?
Type:
OYes QNo
*Pre Treatment:
Drain field
1 3 0 9 Sq. ft.
3
3 a 8 ft.
— 9 Inches O.C.
Feet O.C.
Inches
3 Feet
inches
Minimum Trench Depth: 3
2660 US Hwy 64 W
Inches
Mocksville
NC 27028
Inches
Structure:
SINGLE FAMILY
Inches
# of Bedrooms.
3
# of People:
3
"Water Supply:
PUBLIC
*IP Issued by 2140 -Nations, Robert
*CA issued by: 2140 -Nations, Robert
Design Flow: 3 6 0
Soil Application Rate: 0 a 7 5
Nitrification Field
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Aggregate Depth:
Directions
Hwy 64 West, Pass Vanzant Rd on the left, continue _
about 40 feet home on the right
*System Classification/Description:
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
Seprolite System? OYes QNo
*Distribution T GRAVITY- SERIAL Pump Required?
Type:
OYes QNo
*Pre Treatment:
Drain field
1 3 0 9 Sq. ft.
3
3 a 8 ft.
— 9 Inches O.C.
Feet O.C.
Inches
3 Feet
inches
Minimum Trench Depth: 3
6.
Inches
Minimum Soil Cover. a
4
Inches
Maximum Trench Depth: 3
6
Inches
Maximum Soil Cover. a
1',—Inches
4
*System Type: INFILTRATOR QUICK 4 STANDARD
Installer: Piedmont Backhoe Service
Certification #: 1853
*EH S: 2140 - Nations, Robert
Date: 0 3/ a 9/ a 0 1 6
CDP File Number
201850-1
County ID Number:
Dosing Volume:
—
Gal Certification #:
Septic Tank
Manufacturer.
Taylorsville Precast
Lat.
*Chain:
STB:
1012
Long: ,
1000
Date:
Valves Accessible
Installer. Piedmont Backhoe Service
❑
Gallons:
Flow Adjustment Valve
❑ Yes
❑
NO
Dace:
0
a/ 1$/
NOAppravalStatus
a
Certification #: 1853
0 1 6
PVC unions
El Yes
--�---�--�---
No
❑Approved Disapproved
❑
*EH S: 2140 - Nations, Robert
❑ Yes
*Filter Brand:
TUF-nTE EF -4
�nti-siphon Hole
❑ Yes
0
ST Marker.
p
Yes
❑
No
Date: 0 3/ x 9/ 2 0 1 6
Reinforced Tank:
❑
Yes
®
NO
APPaI Status
®Approved El Dtsappraved
1 Piece Tank:
El
Yes
®No
Pump Tank
Manufacturer,
installer
PT:
Certification #:
Gallons:
THS:
Date:
/
%
Date:
RiserSealed
❑
Yes
❑
No
RiserHeight:
❑
Yes
❑
No
(Min.6 in.)
Approval Status
einforced Tank:
❑
Yes
❑
No
Approved ❑ DlsapprOved
1 Piece Tank:
❑Yes
❑
No
Supply Line
Pipe Size:
inch diameter
Installer.
Pipe Length:
feet
Certification #:
THS:
*Schedule:
Pressure Rated
❑
Yes
❑
No
Date:
Approved fittings
❑
Yes
❑
No�
,ApprovatStatus,
❑Approved ❑ Disapproved=
/ 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
❑
NOAppravalStatus
PVC unions
El Yes
❑
No
❑Approved Disapproved
❑
Vent Hole
❑ Yes
❑
No
�nti-siphon Hole
❑ Yes
0
No
z }
CDP File Number 201850 -1
CI@GLrIG =U1.1101TlellL
County ID Number:
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
*ENS:
Pump Manually Operable
❑
Yes
❑
No
*Activation Method:
Date:
_ Approval Status
Alarm Audible
El
Yes
❑
No
p
Approved❑ Disapproved
Alarm Visible
❑
Yes
13
No
2140 - Nations, Robert
*Operation Permit completed by,
Authorized State
Owner/Applicant Signature:
Date of Issue: 0 3 _/ a 9 / 2 0 1 6
This system has been installed in compliance with.applicabte NC General Statutes: Article 11, Chapter 130A, Rules for
---,Sewage Treatment and Disposal, 15A NCAC 18A.1900 of. Seq., and all conditions of the Improvement Permit and
Construction Authorization This property is served by a TYPE tt A 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. NIA
Management Entity: OWNER
Minimum_System InspectionlMaintenance Frequency By Certified Operator.
NIA
Reporting Frequency By Certified Operator: NIA
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 wrkh a certified operatoror a private certified operator forthe life of the septic system.
Rule .1961 requires that Type VI septic systems designed for a homelbusiness 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 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.
OHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC
Drawing Drawing Type: Operation Permit
10
CDP File Number: 201850 -1
County File Number:
27028 Date: ! /
O Inch
Scale:. OBlock
ON/A
I! II
rb
�C.0
CONSTRUCTION For Office Use Ony
- AUTHORIZATION *CDP File Number 201850- 1
�Y" ✓ Davie County Health Department County ID Number:
210 Hospital Street Evaluated For: NEW
``�
P.O. Box 848 Township: RPrV�cSL
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone: 336-753-6780 Fax: 336-753-1680 0 3/ a 3 a 0 a 1
Applicant: Nathan Singleton
Address: 2660 US Hwy 64 West
City: Mocksville
State/Zip: NC 27028
Phone M (336) 492-2101
�ddress/Road #:
Provisionally suitable
2660 US Hwy 64 W
Mocksville
NC 27028
Structure:
SINGLE FAMILY
# of Bedrooms:
3
# of People:
3
\ *Water Supply:
PUBLIC
Subdivision:
Property Owner: Nathan Singleton
Address: 2660 US Hwy 64 West
City: Mocksville
State/Zip: NC 27028
Phone #: (336) 492-2101
Phase: Lot:
Directions
Hwy 64 West, Pass Vanzant Rd on the left, continue
about 40 feet home on the right
Classification:
Provisionally suitable
Minimum Trench Depth:
a 4
Inches
\Site
Saprolite System?
O Yes ® No
Minimum Soil Cover:
1 a
Inches
Design Flow:3
6 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:
TYPE II A. CONY SYSTEM (SINGLE-FAMILY
OR 480 GPD OR LESS) Septic Tank:
1
0 0 0
Gallons
*Proposed System: 251/16 REDUCTION
1 -Piece:
O Yes
® No
Pump Required: O Yes
® No
O May Be Required
Nitrification Field
1 3
0
9 Sq. ft. Pump Tank:
Gallons
No. Drain Lines
4
1 -Piece:
OYes
ONo
Total Trench Length:
3 a 7
GPM --vs—
ft. TDH
ft
Trench Spacing:O
—
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 01V /
Page 1 of 3
CDP File Number 201850 - 1 County ID Number:
❑ Open Pump System Sheet
red:OYes ®No ONo, but has Available
Trench Spacing: O Inches 0.
*Site Classification: — O Feet O.C.
Design Flow:**** 15A NCAC 1h 1111945 **** 8 Fetes
Soil Application Rate: Aggregate Depth: inches
.�
*System Classification/Descri Minimum Trench Depth: Inches
Repair Area Exenapt— Inches
Maximum Trench Depth:
*Proposed System: Inches
Maximum Soil Cover:
Nitrification Field Sq. Inches
ft.
No. Drain Lines *Distribution Type:
Total Trench Length: ft Pump Required: Oyes O No O May Be Required
Pre -Treatment: O NSF 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. Rm�n
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. Rhm
2000
I
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, Robert Date of Issue: 0 3 / a 3 / a 0 1 6
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
CDP File Number: 201850 - 1
County File Number:
Date: 03 /a3/a016
O Inch
Page 3 of 3
P1 P2
ft.
CONSTRUCTION
AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville D
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Nathan Singleton
For Office Use Only 1
*CDP File Number 201850-1
County ID Number:
Evaluated For NEW
Township:
PERMIT VALID UNTIL:
0 3/ 1 8/ a 0 a 1
Property Owner. Nathan Singleton
(Address/Road #: Subdivision:
266o US Hwy 64 W
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People: 3
*Water Supply: PUBLIC
Phase: Lot:
Directions
Hwy 64 West, Pass Vanzant Rd on the left, continue
about 40 feet home on the right
System Specifications
Address: 2660 US Hwy 64 West
Address: 2660 US Hwy 64 West
4 Inches
City: Mocksville
City: Mocksville
State2ip: NC 27028
State2ip: NC 27028
Minimum Soil Cover:
Phone #: (336) 492-2101
Phone #: (336) 492-2101
(Address/Road #: Subdivision:
266o US Hwy 64 W
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People: 3
*Water Supply: PUBLIC
Phase: Lot:
Directions
Hwy 64 West, Pass Vanzant Rd on the left, continue
about 40 feet home on the right
System Specifications
*Proposed System: 25% REDUCTION
N itrification Field 1 3 0 9
Sq. ft.
No. Drain Lines 4
Total Trench Length: 3 a 7 ft
p 1 0 0 0 Gallons
1 -Piece: QYes @No
Pump Required: QYes ®No OMay Be Required
Pump Tank: Gallons
1 -Piece: QYes QNo
GPM—vs— ft. TDH
Trench Spacing: — 9 Inches O.C.
Feet O.C. Dosing Volume: _ Gallons
Trench Width:@Feet
Inches
3 _
Grease Trap: Gallons
Aggregate Depth: inches Pre Treatment: ONSF OTS -1 OTS -I1
Septic Tank Installer Grade Level Required: 01 011 0111 OIV
Minimum Trench Depth:
a
4 Inches
Site Classification: Provisionally Suitable
Saprolite System? QYes "o
Minimum Soil Cover:
1
a Inches
Design Flow: 3 6 0
Maximum Trench Depth:
3
6 Inches
Soil Application Rate: 0 a 3 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)
Se tic Tank'
*Proposed System: 25% REDUCTION
N itrification Field 1 3 0 9
Sq. ft.
No. Drain Lines 4
Total Trench Length: 3 a 7 ft
p 1 0 0 0 Gallons
1 -Piece: QYes @No
Pump Required: QYes ®No OMay Be Required
Pump Tank: Gallons
1 -Piece: QYes QNo
GPM—vs— ft. TDH
Trench Spacing: — 9 Inches O.C.
Feet O.C. Dosing Volume: _ Gallons
Trench Width:@Feet
Inches
3 _
Grease Trap: Gallons
Aggregate Depth: inches Pre Treatment: ONSF OTS -1 OTS -I1
Septic Tank Installer Grade Level Required: 01 011 0111 OIV
CDP File Number 201850 -1
it S
County ID Number: I
❑ Open Pump System Sheet
ired:OYes O No. ONO, but has Available Space
Trench Spacing:Q Ieet O.C.nches 0.
*Site Classification: — o F
Design Flow:**** 15A NCAC 1 8IFeet
nches
Soil Application Rate: Aggregate Depth: inches
*System Classification/DescriRepair
*Proposed System:
Nkrification Field
No. Drain Lines
Total Trench Length:
Minimum Trench Depth: Inches
Area Exem,,R� Inches
Maximum Trench Depth: Inches
Maximum Soil Cover,
Sq Inches
*Distribution Type:
Pump Required: C7Yes ONo OMay Be Required
ft.
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 bythe Health Department in no way guarantees the issuance of other permfts. The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements.
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 maybe Issued at the same time the Improvement Penult 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 maybe 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? Oyes ONO
Applicant/Legal Reps. Signature: Date: _ / /
*Issued By: 2140- Nations, Robert Date of Issue: 0 3 / 1 8 / a 0 1 6
Authorized State Agent: Malfunction Log Oyes
r,
@Hand Drawing Olmport 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: 201850 -1
County File Number:
Date: 03/18/.1016
Q Inch
Scale: QBlock
QN/A
�I
1
iii
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
CDP File Number: 201850 -1
Mocksville NC 27028 County File Number:
Date: .0.3 / 18 1 2 0 1 6
Click below to Import an image from an external location: Drawing Type: Construction Authorization
Vt
LI%0BLICATION FOR SITE EVALUATION/IMPROVEMENT..PERMIT & ATC"
Application For: 7 Site Evaluation/Improvement Permit C Authoq*p Win To Construct (ATC) ❑ Both
Type of Application: ❑New System ❑Repair to Existing System xpansion/Modification of Existing System or Facility
***IMPORTANT'** THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name �� `a J �I N eContact Person _
Address Home Phone �� j -V O
City/State/ZIP D 0M Business Phone
Email Email:
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
MUMKIY INVUMVIA11VIN Ti)arettouseiracuttyt;ornersrlaggea
NOTE: A survey plat or site plan must accompany this application. Included: U Site Plan UPlat(to scale)
(Permit is valid for 60 months with site plan, no expiration with complete plat.)
Owner's Name i7 W w�e� Phone Number
Owner's Address City/State/Zip
Property Address City
Lot Size. Tax PIN# 01
Subdivision Name if a,� licab�le � le {� Se tto 9t#
nirectinns Ta Site( //1 ZI a] . OOV 7f �f/� 1/a
If the answer to any of the following questions is "Yes",supporting documentation must be attacvd:
Are there any existing wastewater systems on the site?
Yes
No
Does the site contain jurisdictional wetlands?
_Yes
No
Are there any easements or right-of-ways on the site?
Yes
No
Is the site subject to approval by another public agency?
_Yes
_No
Will wastewater other than domestic sewage be generated?
_ Yes
No
IF RESIDENCE FILL OUT THE BOX B LOW
# People # Bedrooms # Bathrooms Garden Tub/Whirlpool I [Yes INo
Basement: :]Yes ❑No Basement Plumbing: Yes :]No
IF NON -RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business Total Square Footage of Building # People
# Sinks # Commodes # Showers # Urinals
Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: # Seats
Type system requested:onventional ❑Accepted ❑Innovative ❑Altemative ❑Other
Water Supply Type: C County/City Water ❑ New Well ❑Existing Well 7 Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? C Yes ❑ No
If yes, what type?
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that
any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if
the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative
of the Davie Country Health Department to conduct necessary inspections to determine compliance with applicable laws and rules.
I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging
or stakyi& the hqu�e/facilitylocatignprypose veil location and the location of any other amenities.
Property owner) or owner a representative signature Site Revisit Charge
/ / Date(s):
3j /� " /& Client Notification Date:
Date EHS:
Sign given I Yes ❑No
Revised 11/06
. t 5.00 I A Iv<,
/� (r Account #
IV/ 71 Invoice #
� U
P I
Parcel #: H2O0000052
Davie County, NC - Basic Estate Search
. Basic Search Real Estate Search Tax Bill Search Sales Search
View Property Record for this Parcel View Mao for this Parcel View Tax Bill Information
Parcel #: H2O0000052
Account #:8304551
Owner Information
Tax Codes
ADVLTAX - COUNTY TA
READVLTAX - FIRE TAX
INGLETON NATHAN R & SINGLETON LYNN
660 HIGHWAY 64 WEST
MOCKSVILLE NC 27028
BXF:
Property Information
Township
Units/Type): 4.500 AC CALAHALN
2(s:2660 W US HWY 64
Deed Information Local Zoning
Pate: 12/2014 Book: 00975 Page: 0959
Plat Book: Page:
Le al Description
PIN
5 AC HWY 64
_
5719138341
Deferred:
2002 WD
Property Values
ulidin :
62,98 0011
BXF:
1,20
nd:
40,58
Market:
104 76
ssessed:
104,764
Deferred:
2002 WD
Sales Information
No.
Book
Page
Month
Year Instrument
Qual/UnQual
Improved
Price
1
00457
0062
12
2002 WD
Unqualified
Improved
0
2
00457
0066
12
2002 WD
Unqualified
Improved
0
3
00459
0083
01
2003 WD
Unqualified
Improved
0
00459
0086
01
2003 WD
Unqualified
Improved
0
00459
0089
01
2003 WD
Unqualified
Improved
0
00975
0959
12
2014 WD
Qualified
Improved
88,000
View Property Record for this Parcel View Mao for this Parcel View Tax Bill Information
Page 1 of 1
qP�t�
0ov14
Davie County Web Site
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=1481961 7/13/2016