1135 Main Church Rd z
OPERATION PERMIT or H ice use nv
Davie County Health Department *CDP File Number. 197605-1
6V_, _14 210 Hospital Street
P.O.Box 848 County ID NumberMocksville NC 27028 Evaluated For, REPAIR
Phone:336-753.6780 Fax:336-753-1680 Township:;
FApplicant: Robin and Thomas Foster Property Owner. Robin and Thomas Foster
Address: 1135 Main Church Road Address: 1135 Main Church Road
City Mocksville City Mocksville
State/Zip: NC 27028 State2ip: NC 27028
Phone#: Phone#:
Property Location & Site Information
Address/Road #: Subdivision: Phase: Lot:
1135 Main Church Road
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY . Hwy 15$ left on Main Ch Rd
#of Bedrooms:
#of People:
*Water Supply: NIA
*IP Issued by. 'System Classification/Description:
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by: 2140.Nations,Robert Saprolite System? QYes QNo
Design Flow: 3 6 0 * GRAVITY-SERIAL Pump Required?
Distribution Type: QYes QNo
Soil Application Rate: 0 a 7 5 *Pre Treatment:
Drain field
(Nitrification Field 1 3 0 9 Sq•ft• *System Type: INFILTRATOR QUICK 4 STANDARD
o. Drain Lines 2 Installer: Jamie games
Total Trench Length: 3 0 0 ft• Certification#: 1018
Trench Spacing: — 9 Inches O.C.
Inches
O.C. *EH S: 2140-Nations.Robert
Trench Width: 3 Inches
)Feet Date: 0 8 / 1 1 / .1 0 1 6
Aggregate Depth: inches
Minimum Trench Depth: 3 6
. _ Inches
Minimum Soil Cover. 4Inches Approval,Status
Maximum Trench Depth: 3 6 ® Approved D Disapproved
Inches
z a=
Maximum Soil Cover:
2 4 Inches
CDP File Number 197605 - 1 Septic Tank County ID Number:
Manufacturer. Let.
Long:
STB: - -
Gallons: installer
Date: / Certification#:
*EHS:
"Filter Brand:
ST Marker. ❑ Yes ❑ No
Date: / 1
Approval Status
Reinforced Tank: ❑ Yes ❑ No
r
-41411-
1 Piece Tank: ❑ Yes ❑ No
❑ Approved D;Dtsapproved
Pump Tank
Manufacturer Installer.
PT: Certification#:
Gallons: THS:
Date: / / Date:
RiserSeaied ❑ Yes ❑ No
RiserHeight: ❑ Yes ❑ No (Min.6 in.)
j Approval Status� �
Reinforced Tank: ❑ Yes ❑ No
D Approved❑ Dtsapproved
1 Piece Tank: ❑ Yes ❑ No
Supply Line
CPipe Size: inch diameter Installer.
Pipe Length: feet Certification#:
*Schedule: THS:
Pressure Rated ❑ Yes ❑ No Date: /
Approved fittings ❑ Yes ❑ No Approval Status
❑ Approved❑"D-
Pump
Requirement
Pump Type: Installer.
Dosing Volume: — Gal Certification#:
Draw Down: Inches THS:
*Chain: /
Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ NO
Check-valve ❑ Yes ❑ NoApproval.Status
PVC unions ElYes ElNo ❑ Approved 0 Dtsapproved
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole ❑ Yes 0 No
CDP File Number 197605 ; 1 County ID Number:
Electric Equipment
NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer.
Box 12 inches Above Grade ❑ Yes ❑ No
Certification#:
Box Box
Pump Tank ❑ Yes ❑ No
Conduit Sealed ❑ Yes ❑ No ''EHS:
Pump Manually Operable ❑ Yes ❑ No
"Activation Method: Date:
Approval Status
Alarm Audible ❑ Yes ❑ No ❑ Approved❑ ,Disapproved
Alarm Visible ❑ Yes ❑ NO ,
2140-Nation,Robert
*Operation Permit completed by:
Authorized State Ag Date of Issue: 0 8 1 1 / 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 TYPE It 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: N/A
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency By Certified Operator:
WA
Reporting Frequency By Certified Operator.WA
Rule .1961 requires that a Type IV and V septic systems designed flora homelbusiness owner must maintain a valid contract
with a public management entitywith a certified operatoror a 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 entitywith a certified operator forthe 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
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**Site Plan/Drawing attached.** `$
OPERATION PERMIT 197605- 1
Davie County Health Department CDP File Number:
210 Hospital Street
P.O.Box W County File Number:
Mocksville NC 27028 Date:
a
Q Inch
Drawin Drawing Type: Operation Permit Scale: . ON A k
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CONSTRUCTION For Office Use Only
A-W.40RIZATION *CDP File Number ,197605-1
°=
Davie County Health Department
County ID Number.
210 Hospital Street Evaluated For. REPAIR
P.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 0 6 / a 8. /, . 2- 0 .2-1-
Applicant:
__1_
Applicant: Robin and Thomas Foster rArdd
erty Owner: Robin and Thomas Foster
Address: 1135 Main Church Road ress: 1135 Main Church Road
City: Mocksville City: Mocksville
State2ip: NC 27028 State/Zip: NC 27028
Phone#: Phone#:
Property Location & Site Information
Address/Road #: Subdivision: Phase: Lot:
1135 Main Church Road
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 158 left on Main Ch Rd
#of Bedrooms: EMAILED
#of People: bate: q
*Water Supply: NiA
System Specifications
Minimum Trench Depth: a 4
rDesign
fication: Provisionally Suitable Inches
- Minimum Soil Cover. 1 a
ystem? ()Yes___- ONo Inches
: 3 6 0 Maximum TrenchDepth: 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.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
Septic Tank:
_ Gallons
'Proposed System: 25%u REDUCTION 1-Piece: OYes ONo
Pump Required: OYes @No OMay Be Required
Nitrification Field 1 3 0 9
Sq. ft. Pump Tank: Gallons
No. Drain Lines 3 1-Piece: OYes ONo
Total Trench Length: 3 a 7 ft GPM—vs— ft. TDH
Trench Spacing: _ 9 W ches t O C.0 Dosing Volume: _ Gallons
Trench Width: Inches
— 3 . Feet Grease Trap: Gallons
Aggregate Depth: inches Pre-Treatment: ONSF OTS-1 OTS-II
Septic Tank Installer Grade Level Required: OI Oil 0111 OIV
Donn 1 nFQ
CDP File Number 197605- 1 County ID Number:
Open Pump System Sheet
Repair System Required:OYes ONo ONo, but has Available Space
epair System
Trench Spacing: Q Inches 0,.0*Site Classification: Q Feet O.C.
Trench Width: QInches '
Design Flow: V Feet
Soil Application Rate: Aggregate Depth: inches
Minimum Trench Depth:
*System Classification/Description: Inches
Minimum Soil Cover. Inches
Maximum Trench Depth:
'Proposed System: _ __.. Inches
- - Maximum Soil Cover:
Nitrification Field Inches
Sq.ft.
No. Drain Cines 'Distribution Type:
=Total Trench Length: ft Pump Required: OYes ONo OMay Be Required
_ Pre Treatment: ONSF OTS-I OTS-II
-Site Modifications
No grading or constriction activity is allowed in areas designated for system and repair without approval of Health Department.
*Permit Conditions
The issuance of this permit by the Health Department in noway guarantees 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)).
ApplicantlLegal Reps. Signature Required? Oyes ONo
Applicant/Legal Reps. Signature: Date:.
Issued By: 2140-Nations,Robert Date of Issue: 0 6 / a 8 / a 0 1 6
Authorized State Agent: Malfunction Log Oyes
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.`*
Page 2 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department CDP File Number: 197605 - 1
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 0 6 / 2 8 / 2 0 1 6
Q Inch
Drawing Drawing Type:-Construction Authorization Scale: . 05lock
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CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital street CDP Fife Number: 197605- 1
P.O.Box 848
Mocksville NC 27028 County File Number:
Date: _0 6 / 2 8 ! 2 0 1 6
Click below to import an image from an extemal location: Drawing Type:Construction Authorization
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Bill ! 113��- JM4WNA 01
DAVIE COUNTY ENVIRONMENT HEALTH SERVICE REQUEST
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APPLICATION IP/ATC OSWW REPAIR &t(d IName Z Telephone Number
Address 69 fflwr
Mailing Address (if different o a
Email Address: l/(1
Subdivision Name #
Directions Al ( 0 b
Date System Ins Iled Name Systein Installed Under
Type Facility Number Bedrooms Number People Served --
Type Wa er Supply Specific Problem Occurring
Date Requested I T 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 RESP N IBLE F AL =AS INFROM THIS APPLICATION. �
Signature of owner or Authorized Agent
Initial Fee Date REHS
Revisit Charge Date Reason
Revised 2-2011