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143 Livengood RdOPERATION PERMIT Davie County Health Department ° ¢ 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Ronald Jones Address: 142 Cedar Hill Lane City: Advance State/Zip: NC 27006 Phone #: Property Loca Address/Road #: Subdivision: 143 Livengood Road Advance NC 27006 Structure: SINGLE FAMILY # of Bedrooms: 3 # of People: *Water Supply: N/A *IP Issued by: *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: *CDP File Number 237709 - 1 5778374515 County ID Number: Evaluated For: REPAIR �ownship: /Property Owner: Ronald Jones Address: 142 Cedar Hill Lane City: Advance State/Zip: NC Phone #: ion & Site Information Phase: Lot: Hwy 64 East, left on Fork Bixby Rd. right on Livengood Rd. Home on left *System Classification/Description: TYPE III G. OTHER NON-CONV. TRENCH SYSTEMS Saprolite System? '.,Yes X, No *Distribution Type: GRAVITY -SERIAL Pump Required? 0 Yes X No, *Pre -Treatment: Drain field 1 a 0 0 Sq. ft. a 304ft. 9 0Inches O.C. (9 Feet O.C. 3 Olnches (9 Feet inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover: a 4 Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: ) 4 Inches Page 1 of 4 *System Type: INFILTRATOR QUICK STANDARD Installer: Sherman Dunn Certification #: 2702 *EHS: 2140 - Nations, Robert Date: 0 5/ 1 1/.1 0 1 7 Approval Status X❑ Approved ❑ Disapproved CDP File Number 237709 - 1 Manufacturer: shoat STB: 1000 Gallons: 1000 Date: 0 a/ a 8/ a 0 1 7 *Filter Brand: POLYLOK PL -122 With Pipe Adapter ST Marker: ❑ Yes ❑X No Reinforced Tank: ElYes \ 1 Piece Tank: ❑X No \ \Piece Tank: ❑ Yes ❑X No Manufacturer: PT: Gallons: Pump Type: Date: / Riser Sealed ❑ Yes Riser Height: ❑ Yes Reinforced Tank: ❑ Yes \ 1 Piece Tank: ❑ Yes / Pipe Size: Pipe Length: *Schedule: Pressure Rated ❑ Yes Approved fittings ❑ Yes County ID Number: 5778374515 septic i anK Lat. ❑ No ❑ No (Min. 6 in.) ❑ No ❑ No Long: In Installer: Sherman Dunn Certification #: 2702 *EHS: 2140 - Nations, Robert Date: 0 5/ 1 1/ x 0 1 7 Approval Status ❑X Approved ❑ Disapproved Pump Tank Installer: Certification #: *EHS: Date: Approval Status ❑ Approved ❑ Disapproved Supply Line inch diameter Installer: feet Certification #: *EHS: ❑ No Date: ❑ No Approval Status ❑ Approved ❑ Disapproved / Pump Type: Dosing Volume: - Draw Down: Inches *Chain: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check -valve ❑ Yes ❑ No PVC Unions ❑ Yes ❑ No Vent Hole ❑ Yes ❑ NO Anti -siphon Hole ❑ Yes ❑ No Installer: Gal Certification #: *EHS: Page 2 of 4 Date: Approval Status ❑ Approved ❑ Disapproved CDP File Number 237709 - 1 NEMA 4X Box or Equivalent ❑ Yes Box 12 inches Above Grade ❑ Yes Box Adj. To Pump Tank ❑ Yes Conduit Sealed ❑ Yes Pump Manually Operable ❑ Yes *Activation Method: Alarm Audible ❑ Yes Alarm Visible ❑ Yes *Operation Permit completed by_ Authorized State Owner/Applicant Signature: County ID Number: 5778374515 ❑ NO Installer: ❑ No Certification #: ❑ No ❑ NO *EHS: ❑ No Date: Approval Status El No ElApproved ❑ Disapproved El No 2140 - Nations, Robert Date of Issue: 0 5/ 1 1/.1 0 1 7 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 iii G. sewage septic system. Rule .1961 requires that a Type TYPE iii G. septic system meet the following criteria: Minimum System Review By The 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 for a 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 for a 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. 9 Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 3of4 OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC Drawing Drawing Type: Operation Permit CDP File Number: 237709 - 1 County File Number: 5778374515 27028 Date: / / O Inch Scale: O Block O N/A Page 4 of 4 P1 P2 P3 OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC CDP File Number: 27028 County File Number: Date:. . / Click below to import an image from an external location: Drawing Type: Operation Permit 5778374515 Page 4 of 4 P1 P2 P3 Drain Field: System Final Inspection Log: Characters Remaining 4000 Septic Tank: Pump Tank: Supply Line: Pump Requirements: Electrical Equipment: P1 P2 P3 Characters Remaining 4000 Characters Remaining 4000 Characters Remaining 4000 Characters Remaining 4000 Characters Remaining 4000