7704 Hwy 801SOPERATION PERMIT
Davie County Health Department
r 210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Bruce Harry
Address: PO Box 357
CRY: Cooleemee
State2ip: NC
Phone #: (336) 284-6180
27014
'CDP File Number 138202-1
M5 -160 -DO -4
County ID Number:
Evaluated For: HDR/WWC
�ownship:
("Property Owner: Cooleemee Church of God
Address: 7704 NC Hwy 801 South
City: Cooleemee
State2ip: NC 27014
one #:
—' Pmperty Location & Site Information
Address/Road #: ubdivision: Phase: Lot:
7704 NC Hwy 801 South
Cooleemee 4 Directions
Struc URCH Hwy 601 South, right on Hwy 801. Church on Right
across from grave yard.
# of Bedrooms:
# of People:
'Water Supply: PUBLIC
'IP Issued by.
'CA issued by: 2140 -Nations, Robert
Design Flow: 1 0 0
Soil Application Rate: 0 - a
'System Classification/Description:
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
SaproliteSystem? OYes QNo
'Distribution Type: GRAVITY - PARALLEL (eq. d -box) Pump Required?
OYes QNo
'Pre Treatment:
J
Drain field
N ilrification Field
5 0 0 Sq. ft.
No. Drain Lines
3
Total Trench Length:
1
6 7 ft.
Trench Spacing:—
9 Inches O.C.
Feet O.C.
Trench Width:Inches
3
— Feet
Aggregate Depth:
inches
Minimum Trench Depth: a
4
Inches
Minimum Soil Cover. 1
a
Inches
Maximum Trench Depth: a
4
Inches
Maximum Soil Cover: 1
a
Inches
'System Type: INFILTRATOR QUICK 4 STANDARD
Installer Randy Miller
Certification #:
'EH S: 2140 - Nations, Robert
Date: 0 8/.2 7 / x 0 1 4
Approval Status
D Approved O Disapproved
CDP File Number 13,8202 -1
Manufacturer. Sh(oaf
STB: 760
Gallons: 1000
Date:
05/
0 4/
2 0 1 4
"Filter Brand:
❑
No
RiserHeight: ❑
Yes
ST Marker:
❑
Yes
E
No
nforced Tank:
❑
Yes
0
NO
1 Piece Tank:
❑
Yes
0
No
Manufacturer.
PT:
Gallons:
Countv ID Number: M5 -160 -Do -4
Let.
Long:
Installer: randy miller
Certification #:
`EH S: 2140 - Nations, Robert
Date: 0 8/ 2 7/ 2 0 1 4
Approval Status
O Approved ❑' Disapproved
Pump Tank
Date:
/
/
RiserSealed ❑
Yes
❑
No
RiserHeight: ❑
Yes
❑
No (Min .6 in.)
nforced Tank: ❑
Yes
❑
No
1 Piece Tank: ❑
Yes
❑
No
Pipe Size: inch diameter
Pipe Length: feet
'Schedule:
Pressure Rated ❑ Yes ❑ NO
ipp roved fittings ❑ Yes ❑ No
Installer:
Certification #:
'EHS:
Date:
Approval Status
❑ Approved ❑ Disapproved
pply Line
Installer.
Certification #:
"EHS:
Date: / /
Approval Status
Approved ❑ Disapproved
(Dosing
PumpType: — Installer:
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 0 Yes ❑ NO
CDP File Number 138202 -1 County ID Number: M5 -160 -DO --4
Electric Eauloment
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:
Alarm Audible
E3
Yes
ElNo
Approval Status
❑ Approved ❑ Disapproved
Alarm Visible
❑
Yes
❑
No
2140 - Nations, Robert
*Operation Permit completed by:
Authorized State Agent: Date of Issue: $ / a 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 TYPE 11 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: N/A
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency By Certified Operator:
N/A
Reporting Frequency By Certified Operator: N/A
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 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.
01 -land 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
CDP File Number. 138202-1
County File Number: MS -160 -DO --4
27028 Date:
O Inch
Scale: OlBlock
ON/A
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HEALTH DEPARTMENT RELEASE
Davie County Health Department
y 210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant:
Bruce Harry
Address:
PO Box 357
City:
Cooleemee
State2ip:
NC 27014
Phone #:
(336) 284-6180
For Office Use Only
*CDP File Number 138202-1
M5 -160 -DO -4
County ID Number.
valuated For. HDR/WWC
PERMIT VALID 0 5/ 1 3/ 2 0 1 9
UNTIL
Property Owner. Cooleemee Church of God
Address: 7704 NC Hwy 801 South
City: Cooleemee
State0p: NC 27014
Phone #:
I-,— Property Location & Site Information
Address 7704 NC Hwy 801 South Subdivision: Phase: Lot:
Road # Cooleemee NC 27014
CHURCH Township:
'Structure: Directions
# of Bedrooms: # of People: Hwy 601 South, right on Hwy 801. Church on Right across from grave
yard.
'Water Supply: PUBLIC
Basement: F] Yes n No
"Proposed Improvement:
Fellowship Hall
Type of Business:
Total sq. Footage: No. Of Employees:
This release in no way expresses or implies that the existing subsurface sewage treatment and disposal
system serving the site will continue to function for any period of time.
Applicant/Legal Reps. Signature Required? OYes ONO
Applicant/Legal Reps. Signature;
*Issued By 2140 -Nations, Robert
Authorized State Agent:
__j
*Date:
*Date of Issue: 0 5/ 1 3/ 2 0 1 4
No
**Site Plan/Drawing attached.**
®Hand Drawing Olmport Drawing
Drawing Type:
HEALTH DEPARTMENT RELEASE
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Health Department Release
CDP File Number: 138202 -1
County File Number: M5 -160 -Do -4
Date: 0 5/ 1 3/ 2 0 1 4
Q Inch
Scale: . QBlock = ,ft.
Q N/A
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APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC
Davie County Environmental Health
RUC EIVP P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
oat�t b (336)753-6780/ Fax (336)753-1680
Application For:., ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct (ATC) ❑ Both
Type ofApplication: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
* * *IMPORTANT* * * THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name rUc.c- 4yrs Contact Person _6ry�e.- 40-0- i
Address_Po P-vvL 3C_-.)-1 Home Phone 336_SL%H- (al gb
City/State/ZIP Q_yo1 e eme.e. ' I4c. X76 ► 4 Business Phone
Email RASA -or bry c e V-,rArM 0) ' rA-rnc. , n' -l -
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
Specify Problem Occurring: "
gud ._. 4b c - J— e KI
6&J Wt Add Au -,a eu; SIS Aln
IF RESIDENCE FILL OUT THE BOX BELOW
# People # Bedrooms # Bathrooms Garden Tub/Whirlpool ❑Yes ❑No
Basement: ❑Yes ❑No Basement Plumbing: ❑Yes []No
IF NON -RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business C\yrvl,. Total Square Footage of Building _+ Lt?l (Db # People
# Sinks q # Commodes # Showers # Urinals /
Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: # Seats
Type system requested: R(!onventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: R<ounty/City Water ❑ New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes &KNo
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 County Health Department to conduct necessary inspections to determine compliance with applicable
laws and les. I understand t t I am responsible for the proper identification and labeling of property lines and corners and
locati agging o t mg tli.lieme/facility location, proposed well location and the location of any other amenities.
Prop owner's or owner' gal representative signature Site Revisit Charge
Date(s):
-Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account # `�2,
Revised 11/06 Invoice #
1
IRS - x
IShelter Shelter
(Gravel Floor) (Concrete Floor)
i Masonry 88Q Pit
v
stied
I
x
Chain Link Fence
---- x -- -- _
v 1 �x
Chain Lir
r-- - - - - - - - - - - - - - - - -
1
1
1
1
I
1
1
1
I
I
Gravel/Grass Parking Lot
1
I
Pro
jrZ.r�
l,ip
40 X (pc
Asphalt Parking Lot
Asphalt Drive
YI V-UndergroundFuel i
�I m Tank Spouts
Stockade Fence -
Stoop do
Handicap Romp
Concrete i — WOik
Parking 7 , I
Area Steps 1 1
Covered Porch 1 1
, r
_ Brick Church rr
O ;;1 PP
-O ,PI o
Q ,CI
of I
IMr
7 1
1 1
1 r
1
Stoop /
L-3 7„7
1" OP FndwM Brick Sign O k` /
/Fnd 1&1/2" EIP
N ° Concrete r
walk -`I r Bent/Fnd
L -1---7-- -M� -�
TP
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PP
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