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221 Pinebrook School Rdr ' OPERATION PERMIT Davie County. Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Steve James Address: 221 Pinebrook School Rd City: Mocksville State2ip: NC 27028 Phone #: (336) 909-3939 Address/Road #: Subdivision: 221 Pinebrook School Road Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 3 # of People: *Water Supply: EXISTING WELL *CDP FileNumber 198788-1 L umber,or REPAIR property Owner Steve James Address: 221 Pinebrook School Rd COY= Mocksville State2ip: NC 27028 hone #: (336) 909-3939 & Site Information Phase: Lot: Directions hwy 158, left on Pinebrook School Rd. Home on left *IP Issued by. 2140 -Nations. Robert *System Classification/Description: TYPE 11 A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140- Nations, Robert SaproliteSystem? 0Yes QNo Design Flow: 3 6 0 *Distribution Type: GRAVITY- PARALLEL (eq.d-bon) PQQYeseQNo? Soil Application Rate: 0 . a 7 5 *Pre Treatment: Drain field Nitrification Field No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: Aggregate Depth: 1 3 0 9 Sq. ft. 6 3 3 2 ft. Inches O.C. +jFeet D.C. 3 Oinches Feet inches Minimum Trench Depth: 3 0 Minimum Soil Cover. 1 8 Maximum Trench Depth: 3 0 Maximum Soil Cover. 1 8 *System Type: INFILTRATOR OUICK 4 STANDARD Installer: Brian McDaniel Certification #: *EH S: 2140 -Nations, Robert Date: 0 1/ 0 8/.2 0 1 6 S ,approved CDP File Number 198788 " I Manufacturer. County ID Number. Septic Tank ' STB: Long: Gallons: Dosing Volume: Installer: - Date: Certification #: Draw Down: *Filter Brand: Yes ❑ No ST Marker: ❑ Yes ❑ No nforced Tank: ❑ Yes ❑ No 1 Piece Tank: ❑ Yes ❑ No Manufacturer. PT: Long: Gallons: Dosing Volume: Installer: - Date: Certification #: Draw Down: RiserSealed ❑ Yes ❑ No RiserHeght: ❑ Yes ❑ No (Min.6 in. nforced Tank: El Yes 13 No t Piece Tank: El Yes El No / Pipe Size: inch diameter Pipe Length: feet *Schedule: Pressure Rated ❑ Yes ❑ No Approved fittings ❑ Yes El No Lat. } Long: , Dosing Volume: Installer: - Certification #: Draw Down: THS: *EHS' Date: Approval Status El Approved ❑' Disapproved Pump Tank No Installer: ❑ Yes ❑ Certification #: Check -valve THS: ❑ No Date: PVC Unions / ❑ Approval Status ❑ Approved ❑ Disapproved Approved ❑ Disapproved Supply Line No Installer. ❑ Yes 0 Certification #: THS: Date: / Approval Status ❑ Approved ❑ Disapproved / PumpType: 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 0 No CDP File Number 198788 -1 =1MAIIG CLILIH IM11L 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 ❑ N o Conduit Sealed ❑ Yes ❑ No *EHS: Pump Manually Operable ❑ Yes ❑ No I *Activation Method: Date: Approval status Alarm Audible ❑ Yes ❑ No 0 ApprovedO� disapproved Alarm visible F-1 Yes 1-1No 2140 - Nations. Robert *Operation Permit completed by: Authorized State Ag� Date of Issue: 0 1 / 0 8 / 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 rem rl A. sewage septic system. Rule .1961 requires that a Type TYPE tl 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 ByCertified Operator: N/A 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 operator or a private certified operator for the life of the septic system. Rule .1961 requires that Type VI septic systems designed fora homelbusiness 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 entry, unless the system owner and certified operator are the same. The contract shall require specific requirements formaintenance and operation, responsibilities of the ownerend 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 subsequentowners of the systems execute such a contract. @Hand Drawing Oimport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC Drawiin;! Drawing Type: Operation Permit CDP File Number: 198788 -1 County File Number: 27028 Date: ! Olnch Scale: OBlock ON/A IT 1 V 7 1 I _ . . ............ i i �r ------------- , k 7jj �.... ............. . - - _-- t I.... ... w ... 1� .-CONSTRUCTION For office Use Only AUTHORIZATION "CDP File Number 198788-1 °--�' Davie County Health Department County ID Number: 210 Hospital Street Evaluated For: REPAIR ., �. P.C. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax: 336-753-1680 1 a/ 3 0/ a 0 a 0 Applicant: Steve James Address: 221 Pinebrook School Rd CRY: Mocksville State/Zip: NC 27028 Phone #: (336) 909-3939 L r Address/Road #: Subdivision: 221 Pinebrook School Road Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 3 # of People: "Water Supply: EXISTING WELL PropertyOwner. Steve James Address: 221 Pinebrook School Rd City: StatetL ip: Phone #: & Site Information Mocksville NC 27028 (336) 909-3939 Phase: Lot: Directions hwy 158, left on Pinebrook School Rd. Home on left System Specifications Minimum Trench Depth: a Inches Site Classification: Provisionally Suitable Saprolite System? OYes %No Minimum Soil Cover. Inches 1 a Design Flow: 3 6 0 Maximum Trench Depth: 3 6 inches Soil Application Rate: 0 - 2 7 5 Maximum Soil Cover: a 4 Inches 'System Classification/Description: "Distribution Type: GRAVITY - PARALLEL (eq. d -box) TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: _ _Gallons `Proposed System: 25°IoREDUCTION 1 -Piece: OYes ONo Pump Required: OYes ONo OMay Be Required Nitrification Field 1 3 0 9 Sq. ft. Pump Tank: Gallons No. Drain Lines 3 v 1 -Piece: ()Yes ONo Total Trench Length: 3 a 7 ft GPMvs— ft. TDH Trench Spacing:— g 2 et Inches O.C. Dosing Volume: _ Gallons Trench Width: 3 0Inches — . OQ Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS -1 OTS -11 Septic Tank Installer Grade Level Required: 01011 0111 OIV CDP File Number 198788 -1 County 10 Number. ' ❑ Open Pump System Sheet RegWrea:v i Ub vlvu Kivu, uUL Ilia, MVd11d1J1C 0 ` "���" —'�" " *Site Classification: Provisionally Suitable Trench Spacing: 9OInches 0. — e Feet O.C. Design Flow: 3 6 0 Trench Width: ,— Inches y 3 • Feet Soil Application Rate:Aggregate � - a � 5 Depth: inches u *System Classification/Description: Minimum Trench Depth: a 4 Inches TYPE II A. CONY 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 No. Drain Lines 1 3 0 9 Sq. ft. 3 Maximum Soil Cover: "Distribution Type: a 4 Inches -' GRAVITY - PARALLEL (eq.d-box) Total Trench Length: 3 a 7 ft Pump Required: Oyes Pro Treatment: ONSF OS No OTS oMay Be Required -1 OTS -II "Site Modifications No grading or construction activity is allowed in areas designated for system and repairwithout 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 Constriction shalt be valid for a person equal to the period of validity ofthe Improvement Perml% not to exceed five years, and maybe issued atthe sametime 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 Authortzaion Is found to have been Incorrect, falsified or changed, or the site Is altered, the permit orConstructlon Authorization shall become Invalid, and maybe suspended or revoked (.1937(8)). 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:. 1 a / 3 0 / a 0 1 5 Authorized States Aye,,.---. _.,..►-�'' Malfunction Log Oyes (J)Hand Drawing Olmport Drawing **Site PIanlDrawing 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 CDP File Number: 198788 - 1 County File Number: Date: 1 :1 / 3 0 2 0 1 5 Oinch Scale: OBIlock ON/A -2� A-6 ---- " I 1 III ------- ----- - ---- ,- � -- ! � 6 a CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Sox 848 Mocksville NC 27028 CDP File Number: 198788" 1 County File Number: Date: _ 12/ 30 / 2 0 1 5 Click below to Impart an Image from an external location: Drawing Type: Constructio 1'v �rCvl IE DAVIE. COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 'NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a Sanita Sege Systems / Permit Number Name pr;�� :f /,;j�/EL fD te_'' N2 7960 Location _ _ __-- �� I �iNe 6 e�• c /ion/��� . Subdivision Name Lot No. Sec. or Block No. Lot Size ----- House Mobile Home ---- Business --- Industry No. Bedrooms —5,2 --.No. Baths — No. in Family Public Assembly Other �Q Garbage Disposal YES ❑ NO Er Specifications for System: Auto Dish Washer • YESNO ❑ Auto Wash Ma^hine YES ,g NO ❑ 5 �/ 1✓� Type Water Supply *This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEETHIS PERMITILAYOUT BEFORE INSTALLING THIS. SYSTEM. J Improvements permit by —,&//)-Z .— *Contact a representative of the Davie County Health Department for final Inspection of this system between 8:30-9:30 A.M., 1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634.5985. Final Installation Diagram: System Installed by tp • /�3— �, E:1 Certificate of Completion __ -- Date 'The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function c �licrnnlnrily inr .— nu,on nnri-4 of fl— A DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) L NAMEe J PHONE NUMBER 1 0 ADDRESS �I N i'C�d /Lj� (�D 1e0(/ SUBDIVISION NAME LOT # DIRECTMS TO SITE % `7 / ✓v ON i/V�i"1/%G}� k (o' DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY J40 USIP,, NUMBER BEDROOMS 3 NUMBER PEOPLE SERVED TYPE WATER SUPPLY Vel% 1 SPECIFY PROBLEM OCCURRING G(� DATE REQUESTED INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowledge. and that I understand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. 1/93 1"-X p DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 'NOTE: Issued in Compliance With Article II of G.S. Chapter 130a Sanita Sege Systems Permit Number Name abate —N2 7960 Location CK s i Subdivision Name Lot No. Sec. or Block No. Lot Size ---- House ,L Mobile Home ---_ Business --_ Industry No. Bedrooms –SJ—No, Baths —z2-- No. in Family Public Assembly Other Garbage Disposal YES ❑ NO a- Specifications for System: Auto Dish Washer YESNO C3.��s Auto Wash Ma•:hine YES �j NO ❑ Type Water Supply -------- -- 'This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEETHIS PERMITILAYOUT BEFORE INSTALLING THIS. SYSTEM. Improvements permit by — J ��— *Contact a representative of the Davie County Health Department for final Inspection of this system between 8:30-9:30 A.M., 1:00.1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704.634-5985. Final Installation Diagram: System Installed by —lrfp �� �c•Qw Ll...0 (� . a D Vz / 1' � �pD X �-fox Certificate of Completion Date 'The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function c�licf�nenril. Inr nn,i nn,on no., nrf n1 /i r..n DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance With Article II of G.S. Chapter 130a Sanitary Sewage Systems _ Nameat l•J%�c�1/fir i �ir'e ♦'.'�"-De 3' i Location ,"--X 0 Permit Number N° 7960 Subdivision Name Lot No. Sec. or Block No. Lot Size --- — House C--' y Mobile Home --_— Business --__ Industry No. Bedrooms—_ No. Baths No. in Family Public Assembly Other Garbage Disposal YES ❑ NO [D- Specifications for System: Auto Dish Washer YESNO [-]Auto Wash Ma^hine YES W NO ❑ -� % , .. Type Water Supply --- /?,, // 'This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE.THIS PERMIT/LAYOUT BEFORE INSTALLING THIS SYSTEM. � �;, Improvements permit by—,�.�'�'/Z-- `Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M., 1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by .4 � �� J - Certificate of Completion-- Date 'The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. DAVIE COUNTY HEALTH DEPARTMENT r IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance With Article II of G.S. Chapter 130a Sanitary Sewage Systems Permit Number Nam ,.�2�._..L�t,�°/., i� �_: % .' ./!LZ—'bate .. ,.`� / N2 7960 Location Subdivision Name Lot No. Sec. or Block No. Lot Size ----_— House !,— Mobile Home ---_ Business -- Industry No. Bedrooms '-- No. Baths —� — No. in Family— Public Assembly Other Garbage Disposal YES ❑ NO p Specifications for System: Auto Dish Washer YES [€] NO ❑ , Auto Wash Ma^hine YES © NO ❑ ��- -�� Type Water Supply 'This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMITOYOUT BEFORE INSTALLING THIS SYSTEM. Improvements permit by — ��— *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30.9:30 A.M., 1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram stem Installed by —«� .y Certificate of Completion ��-- Date <–_ 'The signing of this certificate shall indicate that the system described above has been installed in compliance- with:�.�-- .. the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that'thei�system will function satisfactorily for any,,gi period of time. DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) HONE NUMBER We - f2,gZ UBDIVISION NAME LOT # DIRECTIONS TO SITE i/��f/�o �J�ilr21�1 GdpL. �C �� P�/' - DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY 41ga-5- K NUMBER BEDROOMS NUMBER PEOPLE SERVED TYPE WATER SUPPLY e ��� SPECIFY PROBLEM OCCURRING DATE REQUESTED ��� �3f INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENTgj,,,A"ti Rev. 1/93