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115 Rentz Ln , C)PERATION PERMIT or ice se �v Davie County Health Depa�tment *COP Fi1e Number 136502-1 ,�+�. , � � 210 Hospital Street �rr-aoo-oaot2-a � 4 P.O. Box$48 County 10 Number. �, ,,,, � ''��' Mocksville NC 27028 Evaluated�or. REPAIR . Phone:336-753•6780 Fax:336-753-1680 Township: Applicant: FrBnCeS R�ntz P�operty Owner: Frances Rentz Address: 135 Rentz Lane Address: 135 Rentz Lane C�Y� Mocksville '��Y� Mocksville State2ip: NC 27028 State2ip: NC 27028 Phone#: (336)998-8833 Phone#: (336)998-8833 Pro e Location 8� Site information Address/Road#; Subdivision: Phase: Lat: 115 Rentz Lane Mocksville NC 27028 Directions - - � � Hwy�601 South, Turn left on Deadmon Road, go fo � Structure- � SINGLE FAMILY � _ - - - end, tum left on Hwy 801. Cross Dutchman"s Creek, #of Bedrooms: � .. --. - - _ - , . _, _ _ .. _ � _. Tum left on Joe Road, road on left, Rentz Lane, �of Peopie: DWMH on hill. corner of Joe Road and Rentz Lane *Water Supply: PUBLIC *IP Issued by. *System Classificatan/Desctiption: � : - iYPE II A.CONV SYSTEM(SINGLE•FAMILY OR 480 GPD OR LESSj *CAissuedby: 2�a0-Nauons,Robert Sapro�iteSystem? QYes QNo Design Flow: 3 6 0 * GRAVITY-SERIAL Pump Required7 DistributionType: (�Yes QNo Soil Application Rate: � . 3 'Pre Treatment: Drain fleld N�rification Field 1 a � g Sp•�• *System Type: �N�i��uTa�QuicK a sratvo�o No. Drain lines 4 Instauer: �o�ny�akey ` � Total T�ench length: 3 0 0 �• Cectification#: ��$ Trench Spacing: _ 9 �inches O.C. : Feet O.C. 'EHS: 2�a0-NaGons.Robert Tr�ench Width; 3 Inches — . �Feet Date: � 3 / a 7 / a 0 1 4 Aggregate Depth: inches . . _ _ . . . , . ___ . Minimum Trench Oepth: 3 6 Inches Minimum Soil Cover. a 4 Approval,Stafus Inches Maximum Tr�nch Depth: 3 6 � Approvetl� Disapproved , , Inches Maximum Soil Cover: a q Inches CDP File Number 136502 - 1 County ID Number: K7-aoo-oo-o�z•A ` Se tic Tank Manufacturer. � Lat. � STB: �.ong: � Gailons: Instaper. Date: � � Certification#: `' 'EH S: *Fiiter Brand: ST Ma�cer. ❑ Yes ❑ No Date: , � � Reinforced Tank: ❑ Yes ❑ No �� A�p��sf�� - �� Piece Tanx:�O Yes ❑ No � - � �=C]aApprov�d C��D�sapproved �; �� Pump Tank Manufacturer. Instaqer. PT: Certification#: Gailons: *EHS: Date: � � Dafe: � � RiserSealed ❑ Yes ❑ NO Ri�erNeight: ❑ Yes O No tMin.6 in.) � ,.. „ .. ; ; ;� �PPr�vat Status � einforced Tank:_❑ Yes � ❑ No � � Q �pproved��Disapproved �� 1 Piece Tank: ❑ Yes ❑ No - - Supply Line P�e Size: inch diameter Instaqer. Pipe length: feet Ce�tificatian#: *Schedule: •EN 5: Pressure Rated ❑ Ye5 ❑ No Date: � l App�oved fittings ❑ Yes ❑ NO . Approva!�tatus � ❑ Appcoved� D�sapproved � �� ,, u e Pump Type: Instaqer: Dosing Volume: — Ga� Certification#: Draw Down: Inches *EHS: "Chaan: � � Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Vatve ❑ YeS ❑ NO Check-va�ve ❑ Yes ❑ No Apprcrval'Status� PVC unions ❑ Yes ❑ No = p� Appraved[� Disapproved Vent Note ❑ Yes ❑ No Anti-siphon Hole ❑ Yes ❑ N� . � CDP Fiie Numbe� 136502 - 1 County ID Number. K7-aoo-aaa�z-A Electrtc E ui ment NEMA 4X Box or Equivalent [� Y�5 ❑ Np Instaper. Box 12 inches Above Grade Q Yes � No � Certification#: Box Adj.To Pump Tank ❑ Yes ❑ NO Conduit Sealed ❑ Y�S ❑ �jp 'EHS: Pump ManuatlyOperable ❑ Yes ❑ NO *Activation Method: Date: � � � - �Approval Status AlarmAudibls ❑ Yes ❑ No -O Approved� Disapp�oved � Alarm Visible ❑ Yes ❑ No 2140•Nations,RobeR . 'Operation Permit completed by: Authorized State Agent: Date of Issue: � 3 / a 3 � B a 1 4 � Owner/Applicant Signature: This system has been installed in compliance wth applicable NC General Statutes:Article 11, Chapter 130A� Rules for Sewage Treatment and Disposa1,15A NCAC 18A.1900 et. Seq..and all conditions of the Improvement Permit and Construction Authar¢ation.This prope�ty is served by a TYpE UA. sewage septic system. _ Rule.1961 requires that a Type T�'E II A septic syStem meet the following criteria: M�imum System Review ByThe Local Hea�th Department: wA Management Entity: OWNER _Ma�imum System InspectionMtaintenance F�equencyByCeRified Operator: wA Repo�ting Frequency By Ce�tified Ope�ator:WA Rule .1961 �equires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract wRh a public management entifywxh a certified operatoror a private ce�fified operator forthe life of the septic system. Rule ,1961 requires that Type VI septic systems designed for a home/business owner must maintein a valid contract with a public management entitywith a certified operator for the life of the septic system. Rule. 1961 (2)(e)requires a cont�act shall be executed between the system owner and a management ent�y priar to the issuance of an Operatan Permit for a system required to be maintained bya public or private management ent�y, unless the system ownerand certified operator are the same. The contract shall require specific requirements farmaintenance�nd operation, responsibiities of the owner and systems operator,provisions that the cont�act shall be in effect for as long as the system is in use,and other requirements for the continued proper perfoRnance of the system. It shall also be a cond�ion of the Operation Permit that subsequent owners of the systems execute such a contract. OHand Drawing Olmport Drawing �`*Site PIanlDrawing attached.** 3 ' e � " OPERATION PERMIT 136502 - ') tiavie County Heatth Oepartment CDP File Number: 210 Hospitai Street K7-p00-00-012-A , p.o.�aox$as County File Number: Moc.�sv�ile Nc 2�o2s Date: / / � �_.�__. Q inch Dra�vin� Drawing ype: Operation Permit S��e' ' - . pN q k ' • .ft. I I � _.........._�.�.v_-___�..__ _ � __ I I I __ �W ��. I � � � ..,�' . i ��,_._. � S f � I � I k �,_ � , _ _ �� _ ;�_ . .�^' � � �_ � � I � I � _ __ � �� ..�...: ..._�_.f� . �-;C-�--� � � � �, �� ` ( � �� , � �� - .__ -_- C�- _ __. ____,__ � �� ; � � � � r � � � � �� t �� a � ��' ' � ' 4� � � � �sa �.. � �..��...�� ._ a—`�' c� � � � �;_ r . � __�.. � i � �_ � 1 ► �� I � �; � '� � � � � ��I i� � �.�-.�1 � _ 1 � ► � ; ; � .--.�a__.___.__..___��...5. �.__�______�� mm �I�� ._ l.�.. � t6........, I � I I I �� ! i .� _ , � �� I� . w 1.� �� ... __�._.� �..� ' �� _ � �� . _��__. ; � , -�---�- � , � � �►�....__. � � _�.�__ _i_.�r � w, !�.... � ..�.._..�._. � . _1.� �. , � fi. � .�w.. .��._____�_ ��.� i a�. � n�.�..� � �---��.. � ��__�___i I ; � I � _i � a _ ; 1 � � � 1_� ' ' • ---�-- �CONSTRUCTION For of�ice use on�v AUTHORIZATION *CDP File Number 136502-1 °''S`"`'� Davie Coun Health De artment K�-000-aao�2-A ,� '`~ tY p County ID Number: � '� � 210 Hospital Street Evaivated For. REPAIR �.��;,,,,.� P.O. Box 848 Township: Mocksviile NC 27028 PERt.11T VALID UNTIL: Phone:336-753-6780 Fax:336-753-1680 0 3 � 1 0 � a 0 � 9 Applicant: Frances Rentz Property Owner: Frances Rentz Address: 135 Rentz Lane Address: 135 Rentz Lane CGy: Mocksville Cay: Mocksvilie State2ip: NC 27028 State2ip: NC 27028 Phone#: (336)998-8833 Phone#: (336)998-8833 Propertv Location 8 Site Information ddress/Road#: Subdivisan: Phase: Lot: 115 Rentz Lane Mocksville NC 27028 Directions ructure: SINGLE FAMILY Hwy 601 South, Tum left on Deadmon Road, go to end, turn left on Hwy 801. Cross Dutchman's Creek, Turn left #of Bedrooms: on Joe Road, road on left, Rentz Lane, DWMH on hill. #of People: comer of Joe Road and Rentz Lane 'Water Supply: PueuC System Specifications Minimum Trench Depth: a 4 Site Classificatan: Prov�sronaliy Suitable Inches Minimum Soil Cover. Saprolite System? QYes QNo 1 a Inches Design Flow: 3 6 g Maximum Trench Depth: 3 6 Inches Soil Applicatan Rate: � . 3 � � Maximum Soil Cover: a 4 Inches 'System Classificatan/Description: 'DistributionType: GRAVITY-SERIAL TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 � � g Galtons 'Proposed System: 25%REDUCTION 1-PieCe: QYes QNo Pump Required: �Yes QNo QMay Be Required NQrification Field 1 a � � Sq � PumpTank: Gallons No. Drain Lines 3 1-Piece: QYes QNo Total Trench Length: 3 g � ft GPM—vs— ft. TDH Tr�ench Spacing: _ 9 gFe t 0 C C Dosing Volume: _ Gallons Trench Width: _ Qlnches 3 QFeet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF �TS-I �TS-II SepticTank InstallerGrade Level Required: �) �I) �(II �IV Page 1 oi 3 CDP File Number �36502 - 1 County ID Number: K7-000-00-012-A ❑ Open Pump System Sheet RepairSystem Required:OYeS ONo ONo, but has Availabie Space epair Svstem Trench Spacing: Q Inches 0. . *Site Classification: — Q Feet O.C. Trench Width: Q inches Design Flow: _ �Feet Aggregate Depth: Soil Applicatan Rate: inches � Minimum Trench Depth: Inches *System Classificatan/Description: Minimum Soil Cover. Inches Maximum Trench Depth: *Proposed System: Inches Maximum Soil Cover: N�rification Field Inches Sq.ft. No. Orain Lines 'Distribution Type: Total Trench Length: ft Pump Required: QYes ONo �May Be Required Pre Treatment: ONSF OTS-I OTS-II "Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approvat of Health Department. �•� 7: 'Permit Condltiona The issuance of this permit bythe Health Department in�o wayguarantees the issuance of other permits.The permit hotder is responsible for checking with appropriate goveming bodies in meeting their requirements. °^� �.. 2( Thls Authorization for Wastewxter Systen Constnaction shall be valid tor a person equal to the perlod af wlidtty oithe lmprovement Perml�not to exoeed flve years,and may be Issued at the sametime the Improvpment Pertnit iswed(NCGS 130A-336(b)}.If the instatladon hu not been completed dudng the period ot vatidity of the CorutrucUon Permt;the Irtfamation wbmitied In the appication for a petmlt or ConsVuctioo Authorization is faind tio have bee�ir�cortect,talstiied or changed.orlhe site is altered,the pertnft or ConstrucUon AuthorizaUon shall become Inwtld.and mry be suspended or revoked(.193T(g)).The pefson awning or controlling the system shau be t+espo�IWe ta assuring compliance with the laws,rutes,and permit condltions regardlrg system IocaUon,InstallaUon,openi�on,maintenanc�monitoring,reporting and repalr (1938(b)). ApplicanULegal Reps.Signature Required? OYes �NO ApplicanULegal Reps.Signature� Date: � � 'ISSU6d By: 2�40-Nations,Robe�t Date of Issue: � 3 / 1 0 / a 0 1 4 Authorized State Agent: Malfunctan Log OYes QHand Drawing Olmport Drawing **Site PIan/Drawing attached.** Page 2 of 3 • ' , , CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number. 136502 - 1 210 Hospital Street K7-000-00-012-A P.o.eox sas County File Number: Mocksville NC 27028 Date: 0 3 / 1 0 � � 0 1 1 Q InCh Dra�ving Drawing Type: Construction Authorization Scale: . . . OB�ock � . .ft. QN/A � � -� - ! _i_�____� _ --� _� �_� -� - �__�_---�___��__�_��.�._._.� �.��_j_____) -,= ,--; - (_I--1 I I I I_ _�__I_ I �_._.i � I I I i �I ; i I I i� i i � i � � i____I � � ; �-I i-_-��--+ �-� I I I _i � f I r_�l-�, �_i t I f �_ i �__�__ ! I � ( I __� (i___ i � _ I i � , � - — - —`--__!___t----- I _._.�__..._!_____i , ._I__�._ : __._:_.�__ . ___ __.. 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Box 848 Mocksville NC 27028 TEL: 336-753-6780 pp�; 336-753-1680 Request ID: 46268 REQUEST FOR SERVICE/COMPLAINT INVESTIGATION REPORT !t�QUEST DATE: 02/21/2014 T�N gy; Bonnie �"�CTION: N/A TYPE: PROPERTY NUt�ER: 136502 ASSIGNED TO: Nations, Robert ESTABLISI�NT NUNIDER: PERSON OR PREMISES TO SEE: OWNER: Frances ReIltZ Frances Rentz 135 Rentz Lane 115 Rentz Lane Mocksville , 27028 Mocksville NC, 27028 (336) 998-8833 ' REQIIESTED BY: Owner's Son SOME: WORR: Cell: CONDITION REPORTED:S2ptiC sewage surfacing COt�NTS: RECORD OF INVESTIGATION DATE: HR/MT: CObIl�NTS EHS: E8S #: ACT CODE: DATE: ffit/MT: CObII�NTS EHS: EHS #: ACT CODE: DATE• HR/MT• CO�NTS EHS: EHS #: ACT CODE: DATE: HR/MT: COtM�NTS EHS: EHS #: ACT CODE: DATE: HR/MT• CO2�4�NTS EHS: EHS #: ACT CODE: . �I r1. vH d�V+�(.e �5��°;�v�+� � Next Inspection Date: Status of Complaint: OPEN Resolved Date: Complaintant Contacted: NO _ __ _ _ • �5 /��N-�Z L b�/,'��2 /�� o27d� �;�� DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST APPLICATION IP/ATC OSWW REPAIR '� Name �i�� 'I Iv C S Tel hone Number ��b�?5 �r3�j , Address � N ' �2N �L � Mailing Address (if different from above) -,3 Email Address: K7-0�� (Z� Subdivision Name Lot# 3 Directions -Q D � , N � Z G� h%yl. Date System•Installed �/V �l! � � ! � Name System Installed Under Type Facility �97� 1�(,{)�� Number Bedrooms Number People Served Type Water Supply Specific Problem Occurring T cSG(� Date Requested � Info Taken By , THIS IS TO CERTIFY HAT 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 Date Reason �J��,Q�� Revised 2-2011