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111 Natures Place Way Lot 2 OPERATION PERMIT orice se ny Davie County Health Department *CDP File Number 201854-1 t< 210 Hospital Street P.O. Box 848 County ID Number: Mocksville NC 27028 Evaluated For: NEW Phone: 336-753.6780 Fax:336-753-1680 Township: Applicant: David and Debbie Taylor/Fishel r roperty owner: David and Debbie Taylor/Fishel M ....s-- ... _ �._•...___ .. _ Address: 123 Natures Place ddress: 123 Natures Place City: Mocksville City: Mocksville StatefZip: NC 27028 State/Zip: NC 27028 Phone#: (336)462-4125 Phone#: (336)462-4125 Property Location & Site Information Address/Road #: Subdivision: Nature Place Phase: Lot: 2 123 Natures Place Mocksville NC 27028 Directions Structure; SINGLE FAMILY Hwy,158 East left on Main Church Rd. 1 mile on left #of Bedrooms: 3 #of People: "Water Supply: NEW WELL *IP Issued by. *System Classification/Description: _. TYPE II A CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) 'CA issued by: 2140.Nations,Robert SapraliteSystem7 OYes QNo Design Flow; 3 6 0 GRAVITY-SERIAL Pump Required? Distribution Type: QYes (DNo Soil Application Rate: 0 - 2 5 *Pre Treatment: Drain field Ntrification Field 1 4 4 0 Sq. ft. *System Type: INFILTRATOROUICK4STANDARD No. Drain Lines 3 Installer: Frank Transou Total Trench Length: 3 6 a ft. Certification#: 2771 Trench Spacing: — 9 Inches O.C. Feet O.C. 'EH S: 2140-Nations.Robert Trench Width: 3 Inches Feet Date: 1 0 / 0 3 / 2 0 1 6 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4Inches . Approval�5tatus'; , Maximum Trench Depth: 3 6 Inches IR Approve d0 Disapproved Maximum Soil Cover: a 4 Inches 4185 - 1 CDP Fite Number 20County ID Number: ' Septic Tank - Manufacturer. -Sheaf Let. STB: 1000 Long: , Gallons: 1000 Installer Frank Transou Date: @ 3 / 1 3 / x 0 1 6 Certification#: 2771 *EHS: 2140-Nations,Robert *Filter Brand: POLYLOK PLA 22 With Pipe Adapter ST Marker: El Yes E No Date: 1 0 / 0 3 x 0 1 6 / Reinforced Tank: El Yes Q No Approval Status ® Approved❑ Disapproved" 1 Piece Tank: ❑ Yes ® No z - Pump Tank Manufacturer. Installer-. PT: Certification#: Gallons: *EHS: Date: / 1 Date. Riser5ealed ❑ Yes ❑ No Rises Height: ❑ Yes ❑ Np (Min.6 in.) "Approval Status Reinforced Tank: ❑ Yes ❑_ No ❑"'A ` roved❑ fDlsa pp pp roved,, t Piece Tank: ❑ YeS ❑ No Supply Line Pipe Size: inch diameter Installer: Pipe Length: feet Certification#: *Schedule: *EHS: Pressure Rated ❑ Yes ❑ No Date: Approved fittings ❑ Yes ❑ No Approval Status ❑ Approved❑ =Disapproved Pump Requirement r PumpType: Installer: osing Volume: — Gal Certification#: Draw Down: Inches 'EHS: 'Chain: Date: Valves Accessible ❑ Yes ❑ NO Flow Adjustment Valve ❑ Yes ❑ No Check-valve ❑ Yes El No Approval Status PVC unions ❑ Yes ElNo Approved❑` Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ Yes ❑ NO CDP File Nufi201854 - 1 ber County ID Number: Electric Equipment N EMA 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 ❑ Yes ❑ NO `❑ Approved❑ Disapproved Alarm Visible ❑ Yes ❑ No 2140-Nations,Robert *Operation Permit completed by: Authorized-State Agent: - Date of Issue. 3 / a 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 II A. sewage septic system. Rule .1961 requires that a Type. TYPE Ilk septic system meet the following criteria: Minimum System Review ByThe Local Health Department: NIA Management Entity:_ OWNER Minimum System Inspection/Maintenance Frequency ByCertified Operator: NIA _ Reporting Frequency By Certified Operator: NIA Rule.1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract with a public management entity with a certified operatoror a private certified operator for the 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 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. eHand Drawing Olmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT Davie County Health Department CDP File Number: 241854 - 1 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: O Inch Drawing Drawing Type: Operation Permit Scale: . OBlock ON/A t i ! kk a Cr. o1� � t -Q C i6�� , l 4...»�.......,..-.....»..«�_�_. 11 ._..._........—.-_.,— ...... _ fig_. _i.-.� - , x f S � = i I } I ! a I I I t I � i % 1 , t k , '01Com ` J I f i , CONSTRUCTION For office Use only AUTHORIZATION 'CDP File Number 201854-1 0.0 Davie County Health Department County ID Number: 210 Hospital Street Evaluated For. NEW P.O. Box 84$ Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone:336-753-6780 Fax:336-753-1680 0 3 / 1 8 / a 0 a 1 Applicant: David and Debbie Taylor/Fishel Property Owner: David and Debbie Taylor/Fishel Builders Inc Builders Inc Address: 123 Natures Place Address: 123 Natures Place City: Mocksville City: Mocksville State2ip: NC 27028 State2ip: NC 27028 Phone#: (336)462-4125 1,,Phone#: (336)462-4125 Property Location & Site Information Address/Road #: Subdivision: Nature Place Phase: Lot: 2 123 Natures Place Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 158 East left on Main Church Rd. 1 mile on left #of Bedrooms: 3 #of People: "Water Supply: NEW WELL System Specifications Minimum Trench Depth: a 4 rDesign assification: Provisionally Suitable Inches Minimum Soil Cover. 1 a Inches te System? QYes Flo Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 a 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: Q Yes Q N o Pump Required: QYes QNo QMay Be Required Nitrification Field 1 4 4 0 Sq. ft. Pump Tank: Gallons No. Drain Lines 3 1-Piece: QYes QNo Total Trench Length: 3 6 0 GPM—vs— ft. TDH Trench Spacing: _ 9 Olnches O.C.Feet O.C. Dosing Volume: _ Gallons Trench Width: _ Q Inches 3 ®Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-11 Septic Tank Installer Grade Level Required: OI OII O III OIV Qonn � of 4 A • CDP File Number 201854 - 1 County ID Number: ' ❑ Open Pump System Sheet Repair System Required:Wes ONO ONO, but has Available Space rDesign System Trench Spacing: 9 Q Inches O.C. ification: Provisionally Suitable — e Feet O.C. Trench Width: Inches w: 3 6 0 3 Feet SoilAggregate Depth: Application Rate: 0 - .1 5 inches *System Classification/Description: Minimum Trench Depth: a 4 Inches TYPE IIA CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS; Minimum Soil Cover. 1 a Inches *Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Nitrification Field 1 4 4 0 Sq. ft. Maximum Soil Cover. a 4 Inches No. Drain Lines 3 *Distribution Type: GRAVITY-SERIAL Total Trench Length: 3 6 0 ft Pump Required: Oyes @No OMay Be Required PreTreatment: 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 bevalid for a person equal to the period of validity of the Improvement Permit,not to exceed five years,and may be issued atthe same time the Improvement Permit issued(NCGS 130A-336(b)k 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 3 / 1 8 / .2 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: 201854 - 1 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: 0318 / 0 1 6 Q Inch A DmwinP- Drawing Type: Construction Authorization Scale: . ON/10 ft. Q N/A a _ w� _�. I � 1 1A CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: 201854 - 1 P.O.Box 848 Mocksville NC 27028I I�>� County File Number: 7 _ ' ) k / (e Date: _0 3 1 18 1 0 1 6 Click below to Import an image from an external location: ction Authorizations a-� - z� r � oaf 16 ��u ,✓ OA A �} 1. 36 ` a 1 R 'fit a x d.S+ ^✓ lia to K" '"p - Y �} t � r_}+.<�?x'�..:•t�5i�"'i$k-=! t�.; <� r be'i.'?�'}v r�� zs_�`�'t � '7 a. r `";. 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JUL � , Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 A plication fj(I DMNO i htion/lm ovement Permit uthorization To Construct(ATC) ❑ Both DAVfE IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed _ .� 1 9�G�, C Contact Person Billing Address uJ1)F e,2 a &,,z sHome Phone , Z City/State/ZIPp ,c 'rA,x� ,�� .`1�c �-- !: e Business Phone —S Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION NOTE: A survey'plat or site plan must accompany this application. (Permit is viiUd for 60 on s nth site plan,no expiration with mplete plat. p Street Address ' .N eh /K0/• City Tax PIN# Subdivision Name (I Section/Lo t# Lot Size 'q_� k x S34 Rik 3� T -. Directions To Site: t" J;�c�,�� � �%y,p Date House/Facility Corners,Flagged b�� 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? es i Does the site contain jurisdictional wetlands? ❑Yes EiNo Are there any easements or right-of-ways on the site? ❑Ye)„""" Is the site subject to approval by another public agency? ❑Yes iIo Will wastewater other than domestic sewage be generated? ❑Yes QdI— IF RESIDENCE FILL OUT THE BOX BELOW #Peo le #Bedrooms #�throoms Garden Tub/Whirl ool ❑Yes PFO Basement: es []No Basement Plumbing: EL; es ❑No p 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 ❑Innovative ❑Alternative ❑Other Water Supply Type:V<ounty/City Water ❑New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 4-No If yes,what type? 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 permit(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 understand that I am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine com liance with applicable laws and rules on the above described property located in Davie County and owned by Site Revisit Charge Property owner's or owner's legal representative signature -_ Date(s): 7 ,92, 66 Client Notification Date: Date EHS: �! V Sign given ❑Yes ❑No Account# V5 Revised 2/06 Invoice# �57� Davie County,North Carolina Spatial Data Explorer Pagel of 2 • op(ass � n Spatial Data J=cplOrer ®� pU 10.C, North Carolina Click on the Map to: Map U Zoomin ( ZoomOut l: Recenter Map r ldentify: Parcels Draw L Draw Zoom Factor. 2X (7 Radius Search(feet)Iv - Boundary select NW E r Census Tre City Bound F-County Zor Multi Syl r E911 Fire 0 r Flood Pane Flood Zone F7 Parcels I�t r School Dis+ L Multi Syl <VVr sous 57 9999 1 Town Zonir r Townships Multi Syl r Voting Pre( Infrastructu r Driveways F-Rail Lines Street Cent F/ USINC Higl Multi Syl SW 4, SE L n Parcel Data Find Adjoining Parcels r Aerial Phot Physical • Land Unit/Type: :/AC F7 Creeks and • Deed Book/Page:00557/0699 E911 Addr( • Deed Date:2004/06/21 Fire Depart • County ID:6500000159 • Sales Price:$0.00 r p • Account Number.000082516230 r Schools • Property Address: • PIN:5739999491 WY Draw L • Legal 110T 2 NATURES PLACE • County Zoning:R-A • Owner Name:STROUPE RONALD J • Census Code: MAP Ci • OwnerlAddress 1:STROUPE RONALD J • City Code: • OwnerlAddress 2.STROUPE PENNY R • Fire District:MOCKSVILLE FIRE This map is preps • OwnerlAddress 3:PO BOX 338 • Flood Zone:ZONE X inventory of real 1 within this jurisdic • CilyState Zip:MOCKSVILLE,NC 27028-0000 • Flood Community:370308 compiled from rei • Land Value:$28,700.00 • Flood Panel.,0075 C plats,and other r and data.Users( • Building Value:$0.00 • Flood Map Date:12-17-1993 hereby notified th http://sdx.roktech.net/servlet/com.esri.esrimap.Esrimap?name=Davie&Cmd=sParce12&PIN... 7/9/2006 ' APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT& : Davie County Health Department EnvironmentaiHealth Section #AY r P.O. Box 848/210 Hospital Street 3 Mocksville, NC 27028 (336)751-8760thr��,t'4! Q7 H ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIR INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed Contact Person C� , _ Mailing AddressHome Phone City/State/ZIP Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address / City/State/Zip 3. Application For: �El"Site Evaluation ❑ Improvement Permit/ATC El Both 4. System to service: Vr H,�ou/se El Mobile Home 11 Business ❑ Industry ❑ Other 5. Type system requested: Lel Conventional ❑ conventional modified ❑ innovative 6. I....f//Residence: # People — # Bedrooms # Bathrooms t Dishwasher Mdarbage Disposal 0-washing Machine ❑Basement%Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 8. Type of water supply: 11County/City l/d/Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ETNo If yes,what type? l� ***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED [BELOW. Eithcr a PLAT or SITE PLAN MUST BESUBAlITTED by the client with THIS APPLICATION. Property Dimensions: n.016 ' AWRITE DIRECTIONS(from Nlocicsville)to PROPERTY: Tax Office PIN: # 44d'�(�1� � 1S f' A ;J Property Address: Road Nantc .1641'A (�/lu�l /�1• ,�os` • I LL 1-44 city/zip A If in a Subdivision provide information,as follows: Namc: Section: Block: Lot: Date home corners flagged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or if the information submitted in this application is falsified or changed. I,also,understand that I ani responsible fur all charges iticu red fn•oi n Ibis application. I,hereby,give consent to the Authorized Representative of the Davie County IIcalth Department to enter upon above described property located in Davie County and owned b to conduct all test'ng procedures as necessary to determine the site suitability DATESIGNATURE TIIIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the fol4ving: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: EHS: Sign given Account No. Revised DCIID(05/03 Invoice No. r DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001389 Tax PIN/EH#: 5739-99-8243.02 Billed To: Ron &Penny Stroupe Subdivision Info: Stroupes Lot#02 Reference Name: Location/Address: Main Church Road-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: V Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit E Cut \ FACTORS 1 2 3 4 5 6 7 Landscape position L, Slope% HORIZON I DEPTH �! Texture group Consistence Structure Mineralogy HORIZON Il DEPTH v/" Texture group Consistence Structure L Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: G � _ EVALUATION BY:ZZ. l� LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: LEGEND Landscape Position R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope Texture S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm Wet NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic Structure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogy 1:1,2:1,Mixed Notes Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface Saprolite-S(suitable),U(unsuitable) Soil wetness-Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification-S(suitable),PS(provisionally suitable),U(unsuitable) LTAR-Long-term acceptance rate-gal/day/ft2 DCHD 05/99(Revised)