1139 Milling Rd (2)OPERATION PERMIT
Davie County Health Department
* .-* 210 Hospital Street
r�
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Timothy Chance Barnes
Address: 1139 Milling Road
City: Mocksville
State/Zip: NC 27028
Phone #:
Address/Road #:
1139 Milling Road
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
*Water Supply: PUBLIC
*IP Issued by: 2140 - Nations, Robert
*CA issued by: 2140 - Nations, Robert
Subdivision:
Design Flow: 3 6 0
Soil Application Rate: a 7 5
Nitrification Field
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Aggregate Depth:
r
*CDP File Number 228406 - 1
5748990824
County ID Number:
Evaluated For: REPAIR
'\�ownship:
Property Owner: Timothy Chance Barnes
Address: 1139 Milling Road
City: Mocksville
State/Zip: NC 27028
Phone #:
Phase: Lot:
Directions
Hwy 158 right on Milling Rd on left past Elisha Creek
*System Classification/Description:
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
Saprolite System? O Yes (9 No
*Distribution Type: GRAVITY -SERIAL Pump Re uired?
Q Yes � No
*Pre -Treatment:
Minimum Trench Depth:
1 a
a
4 Sq. ft.
5
1
a
Inches
306ft.
6
Inches
Maximum Soil Cover:
a
4
9
Q Inches O.C.
® Feet O.C.
3
Q Inches
® Feet
0
inches
Minimum Trench Depth:
a
4
Inches
Minimum Soil Cover:
1
a
Inches
Maximum Trench Depth: 3
6
Inches
Maximum Soil Cover:
a
4
Inches
Page 1 of 4
*System Type: 25916 REDUCTION INNOVATIVE OR
Installer: Jamie Barnes
Certification #: 1018
*EHS: 2399 - Eldridge, Tiffany
Date: 0 7/ a 6/ a 0 1 6
Approval Status
® Approved ❑ Disapproved
CDP File Number 228406 - 1
Manufacturer:
No
Gallons:
STB:
Date:
No
Gallons:
Yes
Riser Height: ❑
Date:
nforced Tank: ❑
Yes
*Filter Brand:
Yes
Yes
ST Marker:
❑
Yes
nforced Tank:
❑
Yes
1 Piece Tank:
❑
Yes
❑
No
Manufacturer:
PT:
No
Gallons:
No (Min. 6 in.)
Date:
No
Riser Sealed ❑
Yes
Riser Height: ❑
Yes
nforced Tank: ❑
Yes
1 Piece Tank: ❑
Yes
Countv ID Number: 5748990824
Lat.
Long:
Installer:
/ Certification #:
*EHS:
❑ No Date:
El NO Approval Status
El No ❑ Approved ElDisapproved
❑
No
❑
No (Min. 6 in.)
❑
No
❑
No
/ Pipe Size: inch diameter
Pipe Length: feet
*Schedule:
Pressure Rated ❑ Yes ❑ No
Approved fittings ❑ Yes ❑ NO
Pump Tank
Installer:
Certification #:
*EHS:
Su
Date:
Approval Status
❑ . Approved ❑ Disapproved
pply Line
Installer:
Certification #:
*EHS:
Date:
ApprovalStatus
❑ :Approved ❑ Disapproved
/ Pump Type: Installer:
(/ Dosing 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 ❑
Yes
❑
No
Page 2 of 4
CDP File Number 228406 - 1
County ID Number: 5748990824
NEMA 4X Box or Equivalent
❑
Yes
❑
NO
Installer:
Box 12 inches Above Grade
❑
Yes
❑
NO
Certification #:
Box Adj. To Pump Tank
ElYes
ElNO
Conduit Sealed
❑
Yes
❑
No
*EHS:
Pump Manually Operable
❑
Yes
❑
No
*Activation Method:
Date:
Alarm Audible ❑ Yes
Alarm Visible ❑ Yes
El NO Approval Status
❑ Approved ❑ Disapproved
❑ No J,
2399 - Eldridge, Tiffany
*Operation Permit completed by:
Authorized State Agent: Date of Issue: 0 7 / .2 6 / .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 11 A. sewage septic system.
Rule .1961 requires that a Type TYPE [IA. 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.
® Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 3 of 4
OPERATION PERMIT 228406 - 1
Davie County Health Department CDP File Number:
210 Hospital Street 5748990824 ~
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: / �
O lnch
Drawin� Drawing Type: Operation Permit Scale: . ' p N/A k .ft.
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: Page 4 of 4 P1 P2 P3
OPERATION PERMIT
Davie County Health Department
210 Hospital Street CDP File Number:
P.O. Box 848 5748990824
Mocksville NC 27028 County File Number:
Date:. . . / . . /
Click below to import an image from an external location: Drawing Type: Operation Permit
Page 4 of 4 P1 P2 P3
Drain Field:
Septic Tank:
Pump Tank:
Supply Line:
Pump Requirements:
Electrical Equipment:
System Final Inspection Log:
P1 P2
P3
Chwadws
Remaining
5000
Chau Ws
Remaining
4000
Characters
Remaining
4000
Cheredx$
Remaining
4000
Characters
Remaining
4000
Cha eds
Remaining
4000
wk w Vq
� o �
i
Applicant:
Address:
City:
State/Zip:
Phone #:
CONSTRUCTION
A U TH ORI ZATI O NEMAILED
Davie County Health Departure t
210 Hospital Street1°' �I �� /—•— �—
P.O. Box 848
/ For Office Use Onlv
*CDP File Number 228406-1
County ID Number: 5748990824
Evaluated For. REPAIR
Township:
MOCkSVIIle NC 27028 PERMIT VALID UNTIL:
Phone: 336-753-6780 Fax: 336-753-1680 0 7/ 1 8/ a 0 a 1
Timothy Chance Barnes
1139 Milling Road
Mocksville
NC
i
Address/Road #:
1139 Milling Road
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
"Water Supply: PUBLIC
27028
Subdivision:
Property Owner: Timothy Chance Barnes
Address: 1139 Milling Road
City: Mocksville
State/Zip: NC 27028
Phone #:
Phase: Lot:
Directions
Hwy 158 right on Milling Rd on left past Elisha Creek
System Specifications
D-mnn 1 ^Vl
.
`t
Minimum Trench Depth: a 4 Inches
Site Classification:
Provisionally Suitable
\
Sa rolite System?
p y
QYes QNo
Minimum Soil Cover. 1 a
� Inches
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 QNo
Pump Required: QYes QNo QMay Be Required
Nitrification Field
1 3
0
9 Sq. ft. Pump Tank: Gallons
No. Drain Lines
3
1 -Piece: QYes QNo
Total Trench Length:
3 a 6
ft.
GPM—vs— ft. TDH
Trench Spacing:—
9
QInches O.C. Dosin Volume. _ Gallons
Feet O.C. g
Trench Width:Inches
3
—
.
Feet Grease Trap: Gallons
Aggregate Depth:
inches
Pre -Treatment: ONSF OTS -1 OTS -11
Septic Tank Installer Grade Level Required: 01 OII 0111 O IV
D-mnn 1 ^Vl
CDP File Number 228406 - 1 County ID Number: 5748990824
❑ Open Pump System Sheet
ulred:y i e5 V IVU k NU, UUL lldb-%Vdl!dU!C OPCILM
!Repair System
Trench Spacing:
Q Inches 0.
*Site Classification:
— O Feet O.C.
Trench Width:
0 Inches
Design Flow:
0 Feet
Aggregate Depth:
Soil Application Rate:
-
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.
'Distribution Type:
No. Drain Lines
Total Trench Length:
ft.
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 repair without approval of Health Department.
*Permit Conditions
The issuance of this permit bythe Health Department in no way 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 at the same time the Improvement Permit issued (NCGS 130A -336(b)} 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
OHand Drawing Oimport 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
Drawing Drawing Type: Construction Authorization
�G
CDP File Number: 228406 -1
County File Number: 5748990824
Date: 07 l 1 8 J a s 1 6
Q Inch
Scale: pBlock
()N/A
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
CDP File Number: 228406 - 1
County File Number: 5748990824
Date: 07/ 1 8/ 2 0 1 6
Click below to Import an image from an external location: Drawing Type: Construction Authorization