218 Pinebrook School RdAppSicant Michael Holder
i
Acdress. 230 Pinebrook School Rd
Cly Mocksville
State 2 i:: NC 27028
P, one (336) 239-3693
Property Location &
i Address Roar:
Pinebrook School Road
'CDP File N Umber 121105-1
1`600000042
County ID NUrn ber
Evaluated For. NEW
To.: nsh ip
"Propt,rv0Michael Holder
Address. 230 Pinebrook School Rd
C y Mocksville
State Zip NC 27028
:., Phone= (336) 239-3693
Site Information
Phase. Lot
Mocksville NC 27028 Directions
structure SINGLE FAMILY Hwy 158 E. Left on to Pinebrook School Rd. Poperty
on right just before 230
of bedrooms
OPERATION PERMIT
of People
Davie County Health Department
f
210 Hospital Street
P.O. Box 848
_-;
Mocksville NC 27028
'CA issues by
Phone: 336-753-6780 Fax: 336-753-1680
AppSicant Michael Holder
i
Acdress. 230 Pinebrook School Rd
Cly Mocksville
State 2 i:: NC 27028
P, one (336) 239-3693
Property Location &
i Address Roar:
Pinebrook School Road
'CDP File N Umber 121105-1
1`600000042
County ID NUrn ber
Evaluated For. NEW
To.: nsh ip
"Propt,rv0Michael Holder
Address. 230 Pinebrook School Rd
C y Mocksville
State Zip NC 27028
:., Phone= (336) 239-3693
Site Information
Phase. Lot
Mocksville NC 27028 Directions
structure SINGLE FAMILY Hwy 158 E. Left on to Pinebrook School Rd. Poperty
on right just before 230
of bedrooms
3
of People
2
y 'Water Supp!y
N A
'IP ISSUed by
22.11 - Doy.:a lt. Andre•:.
'CA issues by
22-14 - Davwalt. AndrC:;
'Sys
CI?55,fIC tt0". �P.SC'17;:n11
y
Saprollte System.')
Desuan Flog:
3 6 0 'R;str•,butnn Type N r`
Soil Application Rate 0 2 5 'Pre -Treatment
Wlnfication Field
tJo nraIn l Ines
Total Trenctl Length
Trench Spacing
Trench Vlo'idth
Aggregate Death
Drain field
Sq ft
3 6 0 tt
9 CATItihes 0 C
)Feet O.G.
3 6
rl:i F eCt
riches
t:lsnirnum Trench Dcoth
t:iinim(ir11 SOIL Cover
I,lax IMLIMs Tench Depth. 3 6
Lta)(lnlun: S011 Cover
Inches
lushes
Itiches
Inches
i )Yet!, k o
F.irr Requ c
'System Type INFILTRATOR CUICK A STANDARD
Insta''er
.~bees grading
Certification
'EH S 22.14 - Dayc:alt. Andrev
Dare 0 7/ 2 2% 2 0 1 3
Approval Status
❑ Approved ❑ Disapproved
CDP IF Number 121105 - 1
[,lanufzeti,rrer s=c=ar
STB:
Gallons WOO
Date 0 4/ 0 1/ 2 0 1 3
'Fluter L3anc',
Yes
❑
ST 1.1arker
[ Yes
F- No
e!nfo•ced Tank
❑ Yes
❑ No
I Piece Tank
C Yes
❑ No
t.tall utact°.:re=
PT
Ga`lons
Septic Tank County ID Number:
Lat.
Lona
`[3000WO-12
Installer
Certi'lcation =.
'EHti 22:•t - Da lv-0 A•iCrev.
Date. 0 7/ 2 2/ 2 0 1 3
r Approval Status
❑ Approved ❑ Disapproved
J
Pump Tank
Date
Yes
❑
No
Approval Status
Riser Sea 'ed
❑
Yes
❑
No
Riser lie:glit
❑
Yes
❑
No (t.tln u in ?
snfa-ced Tank
❑
Yes
❑
No
Piece Tank
U
Yes
U
No
Pipe Size inch diameter
P!t;e -erg*h feet
'Schedule
P-essure Rated ❑ Yes ❑ No
Approved it,rigs ❑ Yes ❑ No
Installer.
Colufl: atlorl =-
'EHS
Date / /
Approval Status
❑ Approved ❑ Disapproved
upply Line
Installer
Certification =
'Elis
Date l /
Approval Status
❑ Approved ❑ Disapproved
Pump Tvpe Installer
Dosing Volume - Val Certification -
Drev-- Dov;n Inches 'EHS
Date
......._..__.......
Valves Access,We ❑ Yes ❑ No
F?o:r Adlisstmetit Valve n Yes n No
C�,eck valve ❑
Yes
❑
No
Approval Status
RvC Unions ❑
Yes
❑
No
❑ Approved ❑ Disapproved
'dent Hole U
Yes
U
No
Ants -siphon Hole 0
Yes
❑
No
CDP F.-Ic-.':umber 121105 - 1
IIF1.1A dX Box o- Fcuivalem ❑ Yes
Box 12 inches Above Grade ❑ Yes
Box Adj. To Purnp Tani. J Yes
Co-dwt sealed ❑ Yes
Pump t.ta^uany Operable ❑ Yes
'Activation t ethod
Alarm A;:dible ❑ Yes
Alarm Visible J Yes
'Operation Permit comple'ed by
County ID Number: 'coaoca042
Electric Eauipment
❑ No Installer
❑ No
Cert 5;,ation =
❑ No
❑ No •EIIS
❑ No
Date.
Approval Status
El No
U No ElApproved ❑ Disapproved
22-1-1. - Oayvmr;. Andrei:
Au'horized Sate Agent Date of Issi:e 0 7 / 2 2 / 2 0 1 3
This strslen, has been installed in compliance wth applicable HC General Statutes Art -Ce 1 1. Ct,apter 130A Rules for
Se,. -,-age, Treatment arrd Disposal. 1 5A f1CAC 13A 1000 (?, Seq arrd a I condrions of the Improvement Perm1 a•,d
Co^S1rtic'ion AUthorzat?on This property Is served by a sewage septic system.
mule 1961 requries that a Type -----_—_-- septic systeni n;eet 1,1,,e fol o•:m)g criteria
Mii rnum System Review ByThe Local Health Department
f.1anagenlent Entity —__—, --- —
Llin mum System inspection t.'ari,tenance, FrequencyFiyCeitrfied Operator
Reporting Fregrlency By Cerlif,ed Operator _—
Rule 1961 requires that a Type IV and V septic systems desrgr'ed :or a f.ome business o mer must marntau, a va'rc contract
�; th a public management entity •:; th a cert€tree operator or a private certified operator for the life of the septic system
Rule 19651 requires that Type Vi septic systems designed: fora hone business ov:rn.er must mai^tar.: a val:r'. contra,t with a
public n;anarernent entity wr.l, a ceil1ied operator for the life of the septic systen,
Rule 19.31 (2) (e j requires a cont:'art shall be execriied het:peen 'he systern ov. of r and a managem nt entilty prior to the.
issuance of an Operation Permit for a system reg.=rred to be maintained bya public or private inanagement er,tr.y. unless *,I -,C-.
systeir, ov;ner and cer ified operator are the sante. J tie contract st=all require specitrc requirements for maintenance and
operation responsibiWies of the, o:•;ner arid systems operator provisions that the contract shall be in effect for as long as the
systenn is 1i use. and other requirements for the continued proper performance of Me system I* shall'also be a condition of
the Operation Penn it that subsequeslt o':;nerS Of tt,e systems execute such a COntraC
)Hand Drawing (-)Import Drawing
**Site Plan/Drawing attached.**
Ac'ivty Code S-IS)204 - Or' issued W% Type 11 Quick •1
T^tat -in-e +H-1 t.'f' i
0 1 u_ 0 0
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
%locksville NC 27028
DrawinP,ADrawing Type: Operation Permit
CDP File Number. 121105 - 1
County File Number. U00000-12
Scale
Date:
e > tt'Gh
i `. Block — rt.
1 _A
�Inzlvmov- .,;-sc_Lno( 12d