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1451 Milling Rdr OPERATION PERMIT �o Davie County Health Department 210 Hospital Street t- P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Rita Cassidy Address: 1451 Milling Road City: Mocksville State/Zip: NC 27028 Phone #: (336) 751-9927 Address/Road #: Subdivision: 1451 Milling Road Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 3 # of People: *Water Supply: NEW WELL *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 228436 -1 5759125519 County ID Number: Evaluated For: REPAIR Township: Property Owner: Dwight & Rita Cassidy Address: 1451 Milling Road City: Mocksville State/Zip: NC 27028 Phone #: (336) 751-9927 Phase: Lot: Directions Hwy158, right on Sain Rd. to the end, turn right driveway on the right *System Classification/Description: TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Saprolite System? O Yes (& No *Distribution Type: GRAVITY -SERIAL Pump Re uired? 0 Yes No *Pre -Treatment: Drain field Minimum Trench Depth: 1 3 0 9 Sq. ft. 4 a 4 Inches 3a8ft. 6 Inches Maximum Soil Cover: 9 4 Inches Inches O.C. _ Feet O.C. 3 6 _ Inches Feet inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover: a 4 Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: a 4 Inches *System Type: INFILTRATOR QUICK 4 STANDARD Installer: Randy Miller Certification #: 11281 *EHS: 2325 - Mitchell, Brittany Date: 0 7/ a 6/ a 0 1 6 Approval Status ® Approved ❑ Disapproved c;ur rile Ivumoer Manufacturer: Existing nk county lu Numoer: Lat. STB: Long: Gallons: Installer: Date: / / Certification #: *EHS: *Filter Brand: ST Marker: ❑ Yes ❑ No nforced Tank: ❑ Yes ❑ NO 1 Piece Tank: ❑ Yes ❑ NO Manufacturer: PT: - Gallons: Installer: Dosing Volume: Date: - Riser Sealed ❑ Yes ❑ No Riser Height: ❑ Yes ❑ NO (Min. 6 in.) nforced Tank: ❑ Yes ❑ No 1 Piece Tank: ❑ Yes ❑ No Su Pipe Size: 3 inch diameter Pipe Length: 7 1 feet *Schedule: ao Pressure Rated ❑ Yes ❑ NO Approved fittings ❑ Yes ❑ NO Date: Approval Status Approved ❑ Disapproved Tank Installer: Certification #: *EHS: Date: Approval Status ❑ Approved ❑ Disapproved - pply Line Installer: Randy Miller Certification #: 11281 *EHS: 2325 - Mitchell, Brittany Date: 0 7/ a 6/ a 0 1 6 Approval Status, ® 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 CDP File Number t County ID Number: 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 *EHS: Pump Manually Operable ❑ Yes ❑ No *Activation Method: Date: Approval Status Alarm Audible El Yes 1:1 No ❑ Approved ❑ Disapproved Alarm Visible ❑ Yes ❑ No 2325 - Mitchell, Brittany *Operation Permit completed bye Authorized State Agent: !�`�^� �' t • Date of Issue: 0 7 / a 6 / .1 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. I 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: 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.** UrCMA i ivn rCruvn I Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Drawing Type: Operation Permit CDP File Number: 228436'; 1 County File Number: 5759125519 Date: 07 /a6/a016 O Inch Scale: O Block O N/A N1ia36f U 1� Tax Map Address: Installer: 9gr1dki M i 1 1 e1r EHS: I I Z Date: -7- Z Lo -I Lo Operation Permit Inspection Checklist ❑ Conventional � Chamber ❑ Polystyrene ❑ Other Location and Separation Distances 1. Distance from septic tank/pump tank to foundation/basement 20 feet 2. Distance from system to well if applicable CSS feet 3. Any other setback (.1950) requirements Supply line 1. Material supply line is constructed of FVC 56W90 diameter 3 inches 2. Length of supply line (2' min.) "71 - 3. Amount of fall in supply line (1/8" per foot min) 4. Distance from ST/PT to the nitrification field/dist. device) feet Septic Tank/Pump Tank 1. Visually inspect top of tanks(s), interior & exterior walls, baffle wall and bottom 2. Any honeycombing or exposed rebar present? Circle : YES or NO 3. Visually inspect sanitary tee, lids, and air vent for proper installation and sealant 4. Tank Serial Numbers: STB PT 5. ST Win 6" finished grade? Circle: YES or NO x`IS► 6. Date of manufacture: ST PT 7. Liquid capacity of tanks ST PT 8. Effluent filter tvne 9. Pipe penetration seal present? Circle: YES or NO 10. Riser(s) present? Circle: YES or No Riser Type 11. Pump Tank riser 6" above finished grade? Circle: YES or NO 12. Riser approved? Circle: YES or NO Nitrification Field 1. Septic Tank outlet elevation 2. Trench Depth Readings (inches) ZU 3. Number of Trenches 14 Distance between trenches 4. Trench Width 3(t° 5. Aggregate material type and size 3 4 5 6 57 (Circle) 6. Aggregate Depth (inches) 7. Nitrification lines installed on contour? Circle: W or NO 8. Innovative system type Installer certified for installation? Circle: YES or NO 9. 2' earthen dam between ST (or d -box) and beginning of nitrification line? Circle: YES or NO 10. Stepdowns a. 2' undisturbed earthen dam(s) Circle: YES or NO b. Proper rise over stepdowns? Circle: YES or NO c. Solid pipe used? Solid, Corrugated or other? d. Elevation of each stepdown e. Are all stepdowns lower than the ST outlet elevations? Circle: YES or NO Distribution Devices 1. Type Is the device watertight? Is it level? 2. Distance from Dist. device to trenches feet 3. Record elevations: Inlets Outlets J CONSTRUCTION AUTHORIZATION ° . Davie County Health Department le 210 Hospital Street .� ,. P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 / For Office Use Only *CDP File Number 228436-1 County ID Number: 5759125519 Evaluated For: REPAIR Township: I I VALID UN I IL: 0 7/ a 0/ a 0 a 1 Applicant: Rita Cassidy Property Owner: Dwight & Rita Cassidy Address: 1451 Milling Road Address: 1451 Milling Road City: Mocksville City: Mocksville State/Zip: NC 27028 State2ip: NC 27028 Phone #: (336) 751-9927 Phone #: (336) 751-9927 ( Address/Road #: 1451 Milling Road Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 3 # of People: "Water Supply: NEW WELL Subdivision: Phase: Lot: Directions Hwy 158, right on Sain Rd. to the end, turn right driveway on the right System Specifications Dann 1 nf'Q Minimum Trench Depth: a 4 Inches Site Classification: Provisionally Suitable Saprolite System? OYes Q Minimum Soil Cover. 1 aNo 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: 1 0 0 0 Gallons 'Proposed System: 25% REDUCTION 1 -Piece: OYes QNo Pump Required: OYes QNo ()May Be Required Nitrification Field 1 3 0 9 Sq. ft. Pump Tank: Gallons No. Drain Lines 3 1 -Piece: OYes QNo Total Trench Length: 3 a 7 GPM—vs— ft. TDH ft Trench Spacing: _ 9 Inches O. 2Feet O.C. Dosing Volume: _ Gallons Trench Width: 3 0 inches — , 0Feet Grease Trap: Gallons Aggregate Depth: inches Pre -Treatment: ONSF OTS -1 OTS -II Septic Tank Installer Grade Level Required: OI OII 0111 O IV Dann 1 nf'Q CDP File Number 228436-1 County ID Number: 575st255` 9 ' ❑ Open Pump System Sheet air system Requireo: V T es lJ No V IVO, Dui nas Hvanauie Jpace I V%`W9A11 v'J"111 Trench Spacing: 9 OInches 0., *Site Classification: Provisionally Suitable — © Feet O.C. Design Design Flaw: Trench Width: Inches 3 Feet 3 6 0 _ (� Aggregate Depth: Soil Application Rate: 0 - a 7 5 inches Minimum Trench Depth: a 4 *System Classification/Description: Inches TYPE 11 A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS; Minimum Soil Cover 1 a Inches Maximum Trench Depth: 3 6 'Proposed System: 25% REDUCTION Inches Maximum Soil Cover: a 4 Nitrification Field 1 3 0 9 Inches Sq. ft. No. Drain Lines *Distribution Type: GRAVITY -SERIAL 3 Total Trench Length: 3 a 7 Pump Required: OYes ONo OMay Be Required Pre Treatment: ONSF OTS -1 OTS -11 10 *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 Penult, 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 may be 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 / a 0 / a 0 1 6 Authorized State Agent: Malfunction Log Oyes OHand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box W Mocksville NC 27028 Drawing Drawing Type: Construction Authorization 15- R i CDP File Number: 228436 -1 County File Number: 5759125519 Date: 07/20/,2016 0 Inch Scale: 013lock ON/A Ob I I Ji C., r .. . .......... Co. CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 r CDP File Number: 228436 -1 County File Number: 5759125519 Date: 07/ 20 / a 0 1 6 Click below to Import an image from an external location: Drawing Type: Construction Authorization L APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health �7 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 � %I (336)753-6780/ Fax (336)753-1680 epll at or: .:: Site Evaluation'Im Authorization 7b Construct (ATC) Both 9 o..Application: ';::.':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. Itl99(1[4l.•11filaI UDINTS". 9M Name Q$ S ;tILA Contact Person ; Address Home Phone City/State/ZIP Business Phone - O - Email d C Email: C if Name on Permit/ATDi erei�jjt than b - Mailing Address wi S� 11'x' �.1: n City/State/Lin fA ­ /C< n a FUCA ^a-, YAVYLAI t tiNruiuylAr iuiN 'Late riouse/racinty t timers riaggeo NOTE: A survey plat or site plan must accompany this application. Included: i::f. Site Plan :::I Plat(to scale) (Pennit is valid for 60 mon s with si plan, no expiration with complete plat.) Owner's Name Phone Number 3 (o' ?5'/• Owner's Address % 011 1. City/State/Zip k t• Property Address / City e,,Je- S ti i //v -- Lot v --Lot Size 4a, 1 '7o ar— Tax IN#_.P 67:5�q 1 'M 387-44 Subdivision Name(if applicable) Secti(;n/Lot# Directions To Site: If the answer to any of the following questions is "Yes",supporting documentation must be attached: Are there any existing wastewater systems on the site? � _Yes _ Does the site contain jurisdictional wetlands? _Yes o Are there any easements or right-of-ways on the site? _Yesado Is the site subject to approval by another public agency? _Yes _ o Will wastewater other than domestic sewage be generated? Yes Ao IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms Z, # Bathrooms_ Garden Tub/Whirlpool Yes o Basement: VYcs ":::!No Basement Plumbine: _�4cs :: No IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: :_Conventional ',_ Accepted Annovative Alternative ._:Other. Water Supply Type::::: County/City Water Well Existing Welt Community Welt Do you anticipate additions or expansions of the facility this system is intended to serve? :::: Yes If yes, what type? No 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 pennit(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 ofthe Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand t;a,_,n I res onsible for the proper identification and labeling of property lines and comers and locating and flagging or stal ,� ee/f location pr rosed well location and the location of any other amenities. Prop rty owner's or owmer's legal repretative signature Site Revisit Charge 7 Date(s): Client Notification Date: Date EHS: Sign given :7 Yes ❑ No Revised 11/06 Account # T Invoice # 0 11 Page- Safety- Tocls- ................... .......... . ... .. .. .. . 1453, 1 1" 1546 V 4 5 i ...........................•....___.. ................ 142 5s .. ... ..... ... ...... . ...... . ...... 3394 . . 5392 ... .... . ...... ...... ..... . F, 2 G 8, 1* . . ....... . . . ....... L .. ....... .................. 1 ZA 4260 123 8145 . . ........ 159 01 GG 3CQ4 . .........2121 f /* 40) L!v".. Parcels Results., I Selected Features LDisplay Highlight ParcelNumber NCPinNumber ........ .. ............... . ......... AccountNumber Hamel Name2 Add,.ssi Address2 ..... .... . ...... .... ...... .............. . ......... . .... ................... city State ZipCode LegallDescriptio, TotalA C H600000006 5759IZ5519 14304000 CASSIDY DWIGf-i CASSIDY RITA 1451 MILLING R . ... .............. MOCKSVILLE tic 27028-4303 4.1 AC MILLING 4.17