229 Random RdOPERATION PERMIT
Davie County Health Department �Cj.
210 Hospital Street C
P.O. Box 848 U
1r
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Janice Campbell
Address: 229 Random Road
City Mocksville
State2ip: NC 27028
Phone #: (336) 751-5155
Address/Road #:
229 Random Road
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
*Water Supply: PUBLIC
*IP Issued by.
*CA issued by:
Design Flow: 3 6 0
Soil Application Rate: 0 3
Nitrification Field
No. Drain Lines
Total Trench Length
Trench Spacing:
Trench Width:
Aggregate Depth:
or tce se ny
*CDP File Number 194429-1
J51600007
County ID Number.
Evaluated For. EXPANSION
Township:
Property Owner: Janice Campbell
Address: 229 Random Road
city: Mocksville
State2ip: NC 27028
Phone #: (336) 751-5155
iertv Location & Site Information
Subdivision: Southwood Acres Phase: Lot: 2
Directions
Hwy 601 S. left into Southwood Acres, Left on
Random on the left
*System Classification/Description:
Saprolite System? QYes (j)No
*Distribution Type: GRAVITY - PARALLEL (eq. d -box) Pump Required?
QYes ONo
*Pre Treatment:
Drain fiel
1 a 0 0 Sq. d.
5
3 0 0 ft.
9 (Inches O.C.
eFeet O.C.
Oinch3 & Feet Fe
inches
Minimum Trench Depth: 3
6
Minimum Soil Cover. a
4
Maximum Trench Depth: 3
6
Maximum Soil Cover: a
4
*System Type: INFILTRATOR QUICK 4 STANDARD
Installer: Randy Miller and sons
Certification #:
*EH S: 2140 -Nations, Robert
Date: 0 6/ 0 3/ a 0 1 5
Inches
Inches Approval Status
Inches Lfffll proved ❑ Disapproved
Inches
CDP File Number 194429-1
Manufacturer. Shoaf
STB: 760
Gallons: 1000
Date:
01/
Riser Sealed ❑
14
/ 2 0 1 2
*Filter Brand:
POLYLOK PL -122 With Pipe Adapter
ST Marker:
❑
Yes
2
No
nforced Tank.
❑
Yes
E
No
1 Piece Tank:
❑
Yes
[E]
No
Vent Hole ❑ Yes
❑
No
Anti -siphon Hole ❑ Yes
County ID Number: J51$00007
Let.
Long: .
Installer: Randy Miller and Sons
Certification #:
*EHS: 2140- Nations, Robert
F
Date:
Approval Status
® Approved ❑, Disapproved
Pump Tank
Manufacturer. Installer:
PT: Certification #:
Gallons: *EHS:
Date:
/
Riser Sealed ❑
Yes
Riser Height: ❑
Yes
Reinforced Tank: ❑
Yes
1, ,Piece Tank: ❑
Yes
❑
No
❑
NO (Min.6 in.)
❑
No
❑
NO
Pipe Size: inch diameter
Poe Length: feet
*Schedule:
Pressure Rated ❑ Yes ❑ NO
approved fittings ❑ Yes ❑ No
Date:
Approval Status
L COI Approved ❑ Disapproved
Supply Line
Installer:
Certification #:
*EHS:
Date:
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
D Approved ❑ Disapproved
Vent Hole ❑ Yes
❑
No
Anti -siphon Hole ❑ Yes
❑
No
CDP File Number" 194429 -1
Electric E
NEMA 4X Box or Equivalent
❑ Yes
❑
No
Box 12 inches Above Grade
❑
Yes
❑
No
Box Adj. To Pump Tank
❑
Yes
❑
No
Conduit Sealed
❑
Yes
❑
No
Pump Manually Operable
❑
Yes
❑
No
"Activation Method:
Alarm Audible ❑ Yes ❑ No
Alarm Visible ❑ Yes ❑ No
2140 - Nations, Robert
County ID Number: J51600007
ilpment
Installer:
Certification #:
'EHS:
Date: /
Approval Status
❑ Approved ❑ Disapproved
'Operation Permit completed by:
Authorized State Agent Date of Issue. 0 6 / 0 3 / a fit 1 5
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 sewage septic system.
Rule .1961 requires that a Type
septic system meet the following criteria:
Minimum System Review By The Local Health Department:
Management Entity:
Minimum System Inspection/Maintenance Frequency ByCertified Operator:
Reporting Frequency By Certified Operator:
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 entitywith a certified operatoror a private certified operator forthe life of the septic systema
Rule .1961 requires that Type VI septic systems designed fora home/business owner must maintain a valid contract with a
public management entitywith a certified operator forthe life of the septic system.
Rule. 1961 (2) (e) requires a contract shall be executed between the system ownerand a management entity priorto the
issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the
system ownerand certified operator are the same. The contract shall require specific requirements formaintenance and
operation, responsibilities of the ownerand systems operator, provisions that the contract shall be in effect foras 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 Olmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC
Drawing Drawing Type: Operation Permit
CDP File Number: 194429 -1
County File Number: J51600007
27028 Date:
Q Inch
Scale: QBlock
ON/A
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680
REPAIR OPERATION PERMIT
Accnunt #: 990005872 Tax PIN/EH #: J51600007
Eilied To: Janice Campbell Subdivision Info: Southwood Acres 2 Lot # 2
Reference Name: REPAIR PERMIT LocalioniAddrOss: 229 Random Road -27028
Proposed Facility: Residential Repair Property Sizer :,1;69 Acres
ATC Number: 5923
**NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC has been installed
in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems,"
but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of
time.
System Type:_ S.T. Manufacturer 1( Tank Date Tank Size
Pump Tank Size_, Bedrooms a
System Installed By a Q i�%e Inspector#: Date: �D Z
(:PC ('nnrriin ata•
Environmental Health Specialist: Date:5f O ZZ,
DCHD 11/06 (Revised)
• DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST
APPLICATION IP/ATC OSWW REPAIR
Name
0
Address
Mailing Address (if different from above)
Email Address:
Subdivision Name G1J40 L
Directions M/ S. Let"21 6d .h
fir
Telephone Number
Lot #
Date System Installed I E5 Name System Installed Under
Type Facility /M tae-- Number Bedrooms 3 Number People Served o?
Type Water Supply Aran& Specific Problem Occurring
Date Requested Info Taken By
THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY
KNOWLEDGE, AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED
FROM THIS APPLICATION.
Signature of owner or Authorized Agent
Initial Fee Date REHS
Revisit Charge.
-6$1ti
Date Reason
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990005872 Tax P1hl EH #: J51600007
Billed To: Janice Campbell Subdivision Into:. Southwood Acres 2 Lot # 2
Reference Name: REPAIR PERMIT LocationiAddress- 229 Random Road -27028
Proposed Facility: Residential Repair Property -Size::', , 1.69 A s
Sife Type: ONew epair ❑Expansion
AT**Q* 0� r hist RRhorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental
Health Section prior to.issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A
Wastewater Systems, Section. 1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat
or the intended use change.
Residential Specifications: # Bedrooms # Bathrooms_ # People ( Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size Type of Water Supply: WCounty/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow (GPD) 290 Tank Size ,!C 3k �AL. Pump Tank �� GAL.
Trench Width 'Lls� Max. Trench Depth Rock Depthp& Linear
Site Modifications/Conditions/Other: 'i", n ��
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760.
Environmental Health Specialist.
DCHD 11/06 (Revised)
_I CI-Uu4
vC 1916c)
I
1 ` C
L I
f NUvi c&ff �0LU
GoMAPS - Davie County NC Public Access
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r y %r
O _ r�f''•� f�f
•ti - i �
G'-'rJ
MOCKSVILL
E �, ti•-'`�
***WARNING: THIS IS NOT A SURVEY!***
This map is prepared for the inventory of real property_ found within this jurisdiction, and is compiled from recorded
deeds, plats, and other public records and data. Users of this map are hereby notified that the aforementioned public
primary information sources should be consulted for verification of the information contained on this map. The
County and mapping company assume no legal responsibility for the information contained on this map.
WATERSHED STRUCTURES
WATER BODIES
COUNTY -BOUNDARY
STREETS
RAILROAD CENTERLINE
EJ
PARCELS
CITY-LIM[TS
E] BERMUDARUN
EDCOOLEEMEE
E] DAVIE COUNTY
MOCKSVILLE
Wednesday, May 2 2012