366 Liberty Church RdOPERATION PERMIT
Davie County Health Department,
*s ' 210 Hospital Street
P.O Box 848
-•'- Mocksville NC; 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Thelma Reavis
Address: 138 West Brickwalk Court
City: Mocksville
SWOOP: NC 27028
Phone #:
Property owner. Thelma Reavis
Address: 138 West Brickwalk Court
City: Mocksville
State2ip: NC 27028
(,Phone #:
Pro
a Location & Site Information
dress/Road #:
Subdivision: Phase: Lot:
366 Liberty Church Road
r
Mocksville NC 27028
Directions
Hwy 601 North, to Liberty Church Rd on left
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
'Water Supply: NIA
*System Classification/Description:
'lP Issued by. 21a0-Natr►s,Robert
TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 484 GPD OR LESS)
*CA issued by: 2140 -Nations,
Robert
SaproliteSystem? Oyes )No
Design Flow: 3
6 0
*Distribution Type: Pump Required?
0Yes jj)No
Soil Application Rate: 0 -
a 7
5 'Pre -Treatment:
Drain field
on Field
FNo.
6 7 5 Sq. ft. *System Type: INFILTRATOR QUICK 4 STANDARD
Lines
3
Installer: Randy Miller
Total Trench Length:
a a
5 it. Certification #:
Trench Spacing:
—
9 @FeetInchesO.C.
*EHS: 2140 -Nations, Robert
Trench Width:
—
3 Inches
Feet 0 2/ 1 0/ 2 0 1 6
Date:
Aggregate Depth:
inches
Minimum Trench Depth: 3
6
Inches
Minimum Soil Covera
spa a a
Approval Status;
Inches
Maximum Trench De th:'
p 3
6
Apprcyed Q Disapproed -
Inches
Maximum Soil Cover
Inches
CDP File Number 199938 -1 Septic Tank County ID Number: E3-000-00-017
Manufacturer
STB:
El
No
Flow Adjustment Valve El Yes
Gallons:
No
Check -valve 1-1 Yes
El
Date:
PVC, Unions El Yes
El
*Fitter Brand:
Yes
❑
No
ST Marker.
El Yes
13
No
nforced Tank:
0 Yes
El
No
I Piece Tank:
El Yes
11
No
.I, -
Manufacturer
Let.
Long:
Installer.
Certification 9:
*EH S:
Date:
Pump Tank
PT:
El
No
Flow Adjustment Valve El Yes
Gallons:
No
Check -valve 1-1 Yes
El
Date:
PVC, Unions El Yes
El
RiserSealed E]
Yes
❑
No
RiserHeight: 0
Yes
El
No (Min. 6 in.)
riforced Tank: 0
Yes
El
No
1 Piece Tank: [J
Yes
El
No
Pipe Size: inch diameter
Poe Length: feet
*Schedule:
Pressure Rated 1:1 Yes El No
►pprovedfidtings [:1 Yes El No
Installer
Certification #:
THS:
Date:
SUPPIY Line
Installer
Certification #:
THS:
Date:
Pump Type: Installer.
Dosing Volume: Get Certification#:
Draw Down: Inches *EHS:
*Chain: Date:
Valves Accessible 1:1 Yes
El
No
Flow Adjustment Valve El Yes
1:1
No
Check -valve 1-1 Yes
El
No
PVC, Unions El Yes
El
No
Vent Hole' El Yes
El
N0
Anti -siphon Hole 0 Yes
El
No
CDP Fite Number 199938 -1
County 1D Number: E3.004-00.017
NEMA 4X Box or Equivalent
❑Yes
❑
NO Installer.
Box 12 inches Above Grade
❑
Yes
❑
No
Certification #:
Box Adj. To Pump Tank
❑
Yes
ElNo
Conduit Sealed
❑
Yes
❑
No *EHS:
Pump Manually Operable
❑
Yes
❑
NO
'Activation Method:
Date:
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, l5A NCAC 18A .1900 of. Soq.,,end all conditions of the Improvement Permit and
Construction Authorization. This property is served by.a rnE 11 A. sewage septic system.
Rule .1961 requires that a Type TYPE it septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: NIA
Management Entity: OWNER
Minimum System InspectionNaintenance Frequency By Certified Operator:
NIA
Reporting Frequency By Certified Operator: NIA
Rule .1,961 requires that a Type IV and V septic .systems designed fora home/business owner must maintain a valid contract
With a public management 'entitywiith a certified operatorore 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) (a) requires a contract shall be executed between the system owner and a management envy prior to the
issuance of an Operation Permit for asystem required to be maintained bya public. ar private management entity, unless the
system owner and certified operator are the same. The contract shall require specific requirements formaintenance and
operation,`responsibiities of the owner and systems operator; provisions that the contract shall.be in effect for es long as the
system is'in use, and otherrequirements for the,continued proper performance of the system; It shell also be a condition of
the Operation Permit that subsequentowners bf the systems execute such a contract.
*Hand Drawing almport Drawing
**Site Plan/Drawing attached.** x'
OPERATION PERMIT
Davie County Health Department CDP File Number: 199938 -1
210 Hospital Street E3-000-00-017
P.O. Box 848 County File Number;
Mocksville NC 27028 Date;
Olnch
Drawing Drawing Type: Operation Permit Scale: , OBlock
ON/A
7 lbe
4
Phone #:
(Address/Road M Subdivision:
366 Liberty Church Road
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
*Water Supply: N/A
Phone #:
Phase: Lot:
Directions
Hwy 601 North, to Liberty Church Rd on left
Sife Classification: Provisionanysuiw
CONSTRUCTitJN
Saprolite System? QYes (J)NoInches
For Office Use Only
Design Flow: 3 6 0
AUTHORIZATION
Soil Application Rate: 0 a 7 5
*CDP File Number 199938-1
=
Davie County Health Department
TYPE II A.CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:<
County ID Number E3-000-04.017
�
210 Hospital Street
1 -Piece:_ QYes ONO
Evaluated For REPAIR
•4�,,;,..•
P.O. Box 848
9 Sq. ft. PumpTank: Gallons
Township:
1 -Piece: QYes ONO
Mocksville NC
27028
PERMIT VALID UNTIL:
0Inches O.C. Dosing Volume: _ Gallons
Feet O.C.
Phone: 336-753-6780 Fax: 336.753-1680
0.2/ 1 0/ a 0 a 1
pplicant:
Thelma Reavis
wner Thelma Reavis
rAddress:
138 West Brickwalk Court
FAddress:
138 West Brickwalk Court
Qy:
Mocksville
Mocksville
tate/Zip:
NC 27028
NC 27028
Phone #:
(Address/Road M Subdivision:
366 Liberty Church Road
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
*Water Supply: N/A
Phone #:
Phase: Lot:
Directions
Hwy 601 North, to Liberty Church Rd on left
Sife Classification: Provisionanysuiw
Minimum Trench Depth: 2 4bie Inches \
Saprolite System? QYes (J)NoInches
Minimum Soil Cover. 1 a
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: GRAVITY -SERIAL
TYPE II A.CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:<
Gallons
"Proposed System: 25% REDUCTION
1 -Piece:_ QYes ONO
Pump Required: QYes ONO 0May !Be Required
Nitrification Field 1 3 0
9 Sq. ft. PumpTank: Gallons
No. Drain Lines 3
1 -Piece: QYes ONO
Total Trench Length: 3 a 3 ft.
GPM vs— ft. TDH
Trench Spacing: _ 9
0Inches O.C. Dosing Volume: _ Gallons
Feet O.C.
Trench Width: 3
21nches
Feet
Grease Trap: Gallons
Aggregate Depth: inches
Pre Treatment: ONSF OTS -1 OTS -11
Septic Tank InstallerGrade Level Required: Oi OII 0111 OIV`
e 4 ^f'A
COP File Number 199938 -1
IV
*Site Classification:
Design Flow:
Soil Application Rate:
*System Classification/Description:
*Proposed System:
County ID Number. E3-000-00-017 r t
❑ Open Pump System Sgeet
uired:OYes ONo @No, but has _Available Space
Nitrification Field
Sq. ft.
No. Drain Lines
Total Trench Length: ft.
Trench Spacing:
O Inches 0.1
_ ()Feet 0-C.
Trench Width:Inches
_ Feet
Aggregate Depth:
inches
Minimum Trench Depth:
Inches
Minimum Soil Cover:
Inches
Maximum Trench Depth:
Inches
Maximum Soil Cover:
Inches
*Distribution Type:
Pump Required: Oyes ONo OMay Be Required
Pre Treatment: ONSF OTS -1 OTS -II
*Site Modifications
No,grading or construction activity is allowed in areas designated for system and repairwithout 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 forWastewater System Construction shall be valld for a person equal to the period of validity of the ImprovementPermit! not
yearsto exceed five p ay p unit issued (NCGS 130A-336(b)� tf the Installation has not been
Completed during & erlod of validity of the Construction Perm 1% the information submitted In theapplication for a permit or construction
Authorization is found to have been incorrect, falsified or changed, or the site is altered, the permit orConstruction Authorization shall became
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 a / 1 0 / a 0 1 5
Authorized State Agent: Malfunction Log Oyes t `'
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
__ .._ _. _ _
__ __ _ _ _ _
� ' ,✓ .� •� �' CONSTRUCTION AUTHORI2ATION . 199938 - '1
DavieCountyHeaithDepa�tment CDP File'Number'
210 Hospital Street e�-000-oan��
P.o.aox 8as County File Number:
Mocksville Nc 27o2s Date: 0 � / 1 0 / � � 1 6
�
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SCale: , , . . QBiock = . . � .ft.
D, rawing Drawing Type: nstruction Authorization, - pNiA
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CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P O Box 848
CDP File Number: 199938 -1
Mocksvine NC 27028
County File Number: E3-400-00-017
Date: _0 a/ 1 0/2016
Click below to Import an image from an external location: Drawing Type: Construction Authorization
q
�_ N A a. �•1
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C k
-10'Ito
NCDENR
Division of Environmental Health =Date: 9 2/ 1 0/ 2 0 1 6
Onsite Wastewater Section
Soil/Site Evaluation 'File #: 1 9 9 9 3 8
For On -Site Wastewater System PIN #: E3-000-00-017
*OwnerThelma Reavis Proposed Facility SINGLE FAMILY
Proposed Design Flow (.1949) 3 6 1 Location of Site 366 Liberty. Church Road
Property Size 1.33 WaterSupply NIA Evaluation Method Pit
Profile#
Leh cape
POS
Slope '%
Horizon
Depth
(�a)
SOIL MORPHOLOGY
.1941
Mineralogy Matrix Mottle
TextureStructure Consistence Color Color
Other Profile
Factors
1
L
%
Saprolne: on)
0-48
C
2 -Mod. sbk
8 s p
5YR
416
1942 wet.
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1943 Depth
.1943 Depth
.1944 Rest.
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.1944 Rest.
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.1947. Class
EHS
.1947 Class Ps
EHS
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%
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.1942 Wet.
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Copy ofile
.1942 wet.
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.1943 Depth
.1943 Depth
.1944 Rest.
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.1944 Rest.
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.1947 Class
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.1947 Class
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LTAR
�
Available Space (.1945) S Other Factors(.1946)
Initial LTAR: Repair LTAR: e _ 2 7 5 Others Present:
Comments:
Evaluated By. Nations, Robert
Site Classification (.1948)Ps
I
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1943 Depth
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Initial LTAR: Repair LTAR: e _ 2 7 5 Others Present:
Comments:
Evaluated By. Nations, Robert
Site Classification (.1948)Ps
I
NCDENR
Division of Environmental Health
On -Site Wastewater Section
Soil/Site Evaluation
For On -Site Wastewater System
Date: 0 2 1 1 0 1 a 0 1 6
Fie #: 14493$'
PIN #: E 3 . 0 0 0 0 0 -
Comments:
1 40
Landscape
Horizon
SOIL MORPHOLOGY
.1941
Other Profile
Profile#
°!o
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(IN)
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Factors
SkPipe ;
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.1943 Depth
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