5723 Hwy 801SOPERATION PERMIT
Davie County Health Department
�~ 210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Josh Link
Address: 5723 NC Hwy 801 S
City: Mocksville
State)Zip: NC 27028
Phone #: (336) 909-3912
Property Owner: Nosh Link
Address: 5723 NC Hwy 801 S
City: Mocksville
�State2ip: NC 27028
Phone #: (336) 909-3912
Prooerty Location & Site Information
Address/Road #: Subdivision: Phase: Lot:
5723 NC Hwy 801 S
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy, 601 South, left on Hwy 801. Home on Right
before Dutchmans Creek Bridge
# of Bedrooms:
# of People:
*Water Supply: NIA
- -- *System Classification/Description:
*IP Issued by.
TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by: 2140-NaWns,Roberl Sap[oliteSystem? (Yes }No
Design Flow: 3 6 0 * GRAVITY -SERIAL Pump Required?
*Distribution Type: OYes (j)No
Soil Application Rate: 0 - 3 *Pre Treatment:
Drain field
Nitrification Field
1 3 0 9 Sq. ft.
*System Type: INFILTRATOR OUICK 4 STANDARD
No. Drain Lines
4
Installer: Randy Miller
Total Trench Length:
a
8 8 ft.
Certification #: 1128
Trench Spacing:
inches O.C. O.C.
_ 9 2Feet
*EH S: 2140 -Nations, Robert
Trench Width:
_ 3 Inches
Feet
0 8/ 0 4/ 2 0 1 6
Date:
Aggregate Depth:
inches
Minimum Trench Depth: 3
6
Inches
Minimum Soil Cover, a
4
Inches
Approval Status"
Maximum Trench Depth: 3
6
®Approved D Disapproved
Inches
Maximum Soil Cover. a
4
Inches
CDP File Number 228317 -1
■
f Manufacturer.
STB:
Date:
Gallons:
❑
No
Date:
❑
NO
*Filter Brand:
❑
NoApproval
ST Marker
❑ Yes
❑
No
Reinforced Tank:
❑Yes
❑
NO
1 PieceTank:
❑Yes
❑
No
Countv ID Number:
Let:
Long:
Installer
Certification #:
THS:
Date: ! /
Pump Tank
Manufacturer:
Date:
PT:
❑
No
Gallons:
❑
NO
Date:
❑
NoApproval
RiserSeated ❑
Yes
❑
No
RiserHeght: ❑
Yes
❑
No (Min.6 in.)
Reinforced Tank: ❑
Yes
❑
No
1 Piece Tank: ❑
Yes
❑
No
Pipe Size: inch diameter
Pipe Length: feet
*Schedule:
Pressure Rated ❑ Yes ❑ No
Approved fittings ❑ Yes ❑ No
Installer.
Certification #:
*EH S:
Date:
Supply !rine
- Installer.
Certification #:
THS:
Date:
Pump Type: Installer.
Dosing Volume: — Gal Certification #:
Draw Down: Inches *EH S.
'Chain:
Date:
Valves Accessible ❑ Yes
❑
No
Flow Adjustment Valve ❑ Yes
❑
NO
Check -varve El Yes
❑
NoApproval
Status
PVC Unions ❑Yes
❑
No
❑Approved
❑ Disapprovetl '
Vent Hole ❑ Yes
❑
No
Anti -siphon Hole ❑ Yes
0
NO
CDP File Number 228317 , 1
NEMA 4X Box or Equivalent
Box 12 inches Above Grade
Box Adj. To Pump Tank
Conduit Sealed
Pump M an ually 0 perable
*Activation Method:
Alarm Audible ❑ Yes
Alarm Visible ❑ Yes
2140 -
*Operation Permit completed by_
Authorized State Agent:_
No Approval status
Approved❑ Dlsapprovedj
❑ No
ns,�tobert
Date of Issue. 0 8% 0 4 /.2 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 TvE tit A sewage septic system.
Rule .1961 requires that a Type TYPE 11 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:
NIA
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 operator or a private certified operator for the life of the septic system.
Rule .1961 requires that Type VI septic systems designed fora hometbusiness 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, responsiblities of the owner and systems operator, provisions that the contract shall be in effect for as tong 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
**Site Plan/Drawing attached.**
Electric Equipment
County ID Number:
❑ Yes
❑
No
Installer
❑ Yes
❑
No
Certification #:
❑ Yes
❑
No
❑ Yes
❑
No
*EH S:
❑ Yes
❑
N o
1
Date:
Alarm Audible ❑ Yes
Alarm Visible ❑ Yes
2140 -
*Operation Permit completed by_
Authorized State Agent:_
No Approval status
Approved❑ Dlsapprovedj
❑ No
ns,�tobert
Date of Issue. 0 8% 0 4 /.2 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 TvE tit A sewage septic system.
Rule .1961 requires that a Type TYPE 11 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:
NIA
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 operator or a private certified operator for the life of the septic system.
Rule .1961 requires that Type VI septic systems designed fora hometbusiness 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, responsiblities of the owner and systems operator, provisions that the contract shall be in effect for as tong 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
**Site Plan/Drawing attached.**
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Operation Permit
0
CDP File Number: 228317-1
County File Number:
Date:
Olnch
Scale: 013lock
ON/A
. *CONS.TRUCTION For Office use only
AUTHORIZATION *CDP File Number 228317=1
F
Davie County Health Depattr>t>sNAILED County ID Number.
210 Hospital Street Date; Evaluated For REPAIR
.�;,. P.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone: 336-753.6780 Fax: 336-753-1680 0 3/ 1 8/ a 0 a 1
Applicant:
Josh Link
Property Owner: Josh Link
Address:
5723 NC Hwy 801 S
Address:
5723 NC Hwy 801 S
City:
Mocksville
City:
Mocksville
State2ip:
NC
27028 State2ip:
NC 27028
Phone #:
(336) 909-3912
Phone #:
(336) 909-3912
—
Property
Location & Site Information
/ Address/Road #:
r 5723 NC Hwy 801 S
Mocksville NC 27028
Structure:_ SINGLE FAMILY
# of Bedrooms:
# of People:
'Water supply: wA
Subdivision:
Phase: Lot:
Directions
Hwy 601 South, left on Hwy 801. Home on Right before
Dutchmans Creek Bridge
S
Donn 1 of Z
Minimum Trench Depth: a 4 Inches
Site Classification:
ProvisianallySuitable
Saprolite System?
OYes ONo
Minimum Soil Cover. 1 a
- Inches
Design Flow:
2 4 0
Maximum Trench Depth: 3 6 Inches
Soil Application Rate:
0 - 3
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:
1 -Piece: OYes ONo
Pump Required: OYes @No OMay Be Required
N itrification Field
1 2 0
0 Sq. ft. Pump Tank: Gallons
No. Drain Lines
3
1 -Piece: OYes ONo
Total Trench Length:
3 0 0 ft
GPM—vs— ft. TDH
Trench Spacing:
— 9
0Inches O.C.
Feet O.C. Dosing Volume: _ Gallons
Trench Width:
3
Inches
8—
Feet Grease Trap: Gallons
Aggregate Depth:
inches
Pre Treatment: ONSF OTS -1 OTS -II
Septic Tank Installer Grade Level Required: 01 OII 0111 O IV
Donn 1 of Z
CDP File Number 228317 - 1 County ID Number. . . '
Repair System Required:OYes ONo 'ONo, but has Available S
*Site Classification:
Design Flow:
Soil Application Rate:
*System Classification/Description:
'Proposed System:
Nitrification Field
Sq. ft.
No Drain Lines
❑' Open Pump Systerri Street
Trench Spacing: _ 0Inches 0.1
()Feet O.C.
Trench Width:
0 Inches
Feet
Aggregate Depth:
inches
Minimum Trench Depth:
Inches
Minimum Soil Cover.
Inches
Maximum Trench Depth:
Inches
Maximum Soil Cover:
Inches
*Distribution Type:
Total Trench Length: Pump Required: OYes 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.
*Permit Conditions
The issuance of this permit bythe Health Department in no wayguarantees 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 be valid for a person equal to the period of validity of the Improvement Permit, not
to exceed five years, and maybe Issued atthe same time the Improvement Permit Issued (NCGS 130A-336(11)} 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 7/ 1 8/ 2 0 1 6
Authorized State Agent: Malfunction Log OYeS
UHand 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
DrawinP, Drawing Type: Construction Authorization
CDP File Number: 228317 -1
County File Number:
Date: 07/18/.2016
Q Inch
Scale: QBlock
QN/A
1.7
1
J-
7_7
TF
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital street CDP File Number: 228317 -1'
P.O. Box 848
Mocksville NC 27028 County File Number:
Date:. 07/ 18 ! 2_0 i 6
to
Click below to IrnAt?an Image Irom an extemai location: Drawing Type: Construction Authorization
u�
l� loo too
n, �
DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST
APPLICATION IP/ATC OSWW REPAIR
Name vLb,< Telephone Number
Address 7-33 M S
Mailing Address (if different from above)
Email Address:
Subdivision Name Lot #
Directions
Date System InstalledJ4,qynilklJ �Name System Installed Under (�J�
Type Facility Number Bedrooms Number People Served s
Type Water upply V Specific Problem Occurring I
r - -5hhWjA.Aq w ielr baCALs
Date Requested h �;�0 -I& _ _ _ _ _ _ _ _ _ Info Taken By
THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY
KNOWLEDGE, AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED
FROM THIS APPLICATION.
Signature of owner or Authorized Agent
Initial Fee Date REHS
Revisit Charge Date Reason
Revised 2-2011