1138 Ridge Rd OPERATION PERMIT or ifice t3se UnIV
Davie County Health Department *CDP File Number 194972-1
210 Hospital Street 5707367216
P.O.Box 848 County ID Number.
Mocksville NC 27028 Evaluated For'NEW
Phone:336-753-6780 Fax:336-753-1680 Township.
Applicant: Todd Josey Property Owner. Larry Graham
Address: 226 Morrison Road Address: 173 Raintree Road
City: Mocksville City: Advance
StatefLip: NC 27028 State2ip: NC 27006
Phone#: (336)596-2186 Phone#:
Propeqy Location & Site Information
Address/Road#: - Subdivision: Phase: Lot:
Ridge Road
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 64 W to Ridge Road on left : Property on left
across from Smith Rd
#of Bedrooms: 5
#of People: 5
'Water Supply: NEW WELL
'IP Issued by. 21ao-Nations,Robert 'System Classification/Description:
'CA issued by: 2140-Nations,Robert SaproliteSystem? QYes QNo
Design Flow: 6 0 0GRAVITY-SERIAL Pump Required?
Distribution Type: QYes (bNo
Sail Application Rate: 0 _ a 7 5 'Pre Treatment:
Drain field
rNgnification Field a 1 8 a Sq• ft• 'System Type: INFILTRATOR OUICK 4 STANDARD
rain Lines 5 Installer: Dennisgaaaher
Total Trench Length: 5 4 5 It. Certification#: 1071
Trench Spacing: — 9 ()Inches O.C.
Feet O.C. 'EH S: 2140-Nations.Robert
Trench Width: Inches
3 . Feet Date: 1 1 / 1 7 / 2 0 1 5
Aggregate Depth: inches
Minimum Trench Depth: 3 6
Inches
Minimum Soil Cover. a 4 AppravhStattis
Inches
Maximum Trench Depth: 3 6 Inches ® Approved L7 Disapproved:
Maximum Soil Cover: a 4
Inches
194972 - 1 5707367216 `
CDP File Number County ID Number: '
Septic Tank
( DennManufacturer. shoat Lat.
STB: 964 Long:
Gallons: 1500
Installer
is Gataher
- Date: 0 4 / 0 6 / a 0 1 5 Certification#: 1071
THS: 2140-Nation.Robert
*Filter Brand: POLYLOK PL-122 With Pipe Adapter
ST Marker. El Yes [E No
Date: 1 1 / 1 7 / a 0 1 5
Reinforced Tank: ❑ Yes No Approval Status
Piece Tank: ❑ Yes D No ® Approved❑ =Disapproved
Pump Tank
Manufacturer. Installer:
PT: Certification#:
Gallons: *EHS:
Date: / I Date: I l
RiserSealed ❑ Yes ❑ No
RiserHeght: ❑ Yes ❑ No (Min.6 in.)
Approval Status
Reinforced Tank: ❑ Yes ❑ No
❑ Approved❑ Disapproved
1 Piece Tank: ❑ Yes_ ❑ No
Supply Line
Pipe Size: inch diameter Installer
Pipe Length feet Certification#:
*Schedule: THS:
Pressure Rated ❑ Yes ❑ No Date:
Approved fittings 11Yes ❑ No Approval Status
`❑ Approved❑ ;Disapproved
Pump e e
CDosing
p Type: Installer
Volume: - Gal Certification#:
Draw Down: -Inches *EHS:
*Chain: I /
Date:
Valves Accessible ❑ Yes ❑ NO
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve ❑ Yes ❑ No
_Approval Status
PVC unions ❑ Yes ❑ No ❑ Approved❑ Disapproved„
Vent Hole E] Yes ❑ NO
Anti-siphon Hole ❑ Yes ❑ No
CDP File Number 194972 - 1 County ID Number: 5707367216
Electric Equipment
NEMA4X 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 Audibie ❑ Yes ❑ No _
Approved❑ Disapproved
Alarm Visible ❑ Yes ❑ No
2140-Nation,Robert
*Operation Permit completed by:
Authorized State Age Date of Issue: 1 1 / 1 7 / 2 9 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 By Certified 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 system.
Rule.1961 requires thatType 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 ownerand 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.
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT ,
Davie County Health Department CDP File Number: 194972- 1
210 Hospital Street 5707367216
P.O.Box County File Number.
Mocksville NC 27028 Date:
O1nch
Drawing Drawin Type: Operation Permit Scale: . OBlock
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CONSTRUCTION For Office Use Only
AUTHORIZATION *CDP Fite Number 194972-1
%=' Davie County Health Department county ID Number:5707367216
3 210 Hospital Street Evaluated For NEW
P.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 1 0 / 0 6 / 2 0 2 0
Applicant: Todd Josey Property Owner. Larry Graham
Address: 226 Morrison Road Address: 173 Raintree Road
City: Mocksville CRY: Advance
State/Zip: NC 27028 State2ip: NC 27006
hone (336)596-2186 Phone#:
Property Location & Site Information
r
ad#: Subdivision: Phase: Lot:
ad
e NC 27028 Directions
Structure: SINGLE FAMILY Hwy 64 W to Ridge Road on left: Property on left across
from Smith Rd
#of Bedrooms: 5
#of People: 5
"Water supply: NEW WELL
System Specifications
Minimum Trench Depth: a 4
rDesign
ssification: Provisionanysuibble Inches
Minimum Soil Cover. 1 a
System? QYes ®No Inches
low: 6 0 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 . a 3 5 Maximum Soil Cover: a 4 Inches
*System Classification/Description: *Distribution Type: GRAVITY-PARALLEL(eq.d-box)
TYPE III A.CONY SYSTEM>480 GPD(EXCLUDING SFD) Septic Tank: 1 a 5 0
Gallons
"Proposed System: 25%REDUCTION 1-Piece: QYes QNo
Pump Required: QYes *No Q May Be Required
Nitrification Field a 1 8 a Sq. ft. Pump Tank: Gallons
No.Drain Lines 5 1-Piece: QYes QNo
Total Trench Length: 5 4 5 ft. GPM vs— ft. TDH
Trench Spacing: _ 9 Onches O.C.
Feet O.C. g Dosin Volume: _ Gallons
Trench Width: inches
— 3 _ Feet Grease Trap: Gallons
Aggregate Depth: inches
Pre Treatment: ONSF OTS-1 O.TS-11
.Septic Tank InstallerGrade Level Required: O! OII O III OIV
CDP File Number 194972 - 1 County ID Number. 57073672166 ,
❑ Open Pump System Sheet
Repair System Required:*Yes. ONo ONO, but has Available Space
r-nesign
system
Trench Spacing: 9 (�Inches 0: .
ification: Provisionally Suitable — (*)Feet O.C.
Trench Width: Inches
w: 6 0 0 — 3 . Feet
SoilAggregate Depth:
Application Rate: 0 - a 7 5 inches
Minimum Trench Depth: a 4
*System Classification/Description: Inches
TYPE 111 A.CONY SYSTEM>480 GPD(EXCLUDING SFD) Minimum Soil Cover. 1 a Inches'.
Maximum Trench Depth: 3 6 Inches
"Proposed System: 25%REDUCTION —
Nitrification Field a 1 $ a Sq.ft. Maximum Soil Cover: a 4 Inches
No. Drain Lines 5 *Distribution Type: GRAVITY-PARALLEL(eq.d-box)
TotalTrench Length: 5 4 5 ft Pump Required: OYes ®No ( 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 approval of Health Department.
i
*Permit Conditions
The issuance of this permit bythe Health Department in no wayguarantees 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 bevaltd fora person equal to the period of wiidity of the improvement Permit,not
to exceed five years,and may be issued atthe same time the ImprovementPemtit issued(NCGS 130A-336(11)).If theinstallirtion has not been
completed during the period of wlldity of the Construction Perrntt,the information submitted inthe appliesuon fora permit or Construction
Authorization Is found to have been Incorrect falsified or changed,or the site is altered,the permit orConstruction Authorization shall became
Invalld,and may be suspended or revoked(.1937(g)).The person owning or controlling the system shall be responsible forassuring compliance
with the laws,rules,and permit conditions regarding system location,installation,operation,maeitenancA monitoring,repotting and repair
(1938(b)):
ApplicantlLegal Reps.Signature Required? Oyes ONo
Applicant/Legal Reps.%6ignature: Date:• /
2140-Nations,Ro 1 0 / 0 6 / .1 0 1 5
Issued By: Date of Issue:,.... - -
ot
Authorized State Age Malfunction Log OYes
*Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department CDP File'Number: 194972 - 1
210 Hospital Street
County File Number: 5707367216
P.O.Box 848
Mocksville NC 27028 Date: 1 0 / 0 6 / 2 0 1 5
Q Inch
Drawing Drawing Type: Construction Authorization Scale: . OBlock
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CONSTRUCTION AUTHORIZATION '
Davie County Health Department
210 Hospital Street CDP File Number: 194972- 1
V I P.O.Sox 848 S e: 5707367216
V l M ville NC 1 27028 [ / nty File Number:
1� 12,c- l�c-� Date: 1 0 1 0 6 / 2 0 1 5
Click below to Import Image fr e n an ex�e`m I location: Drawing Type:Construction Authorization
p ±� p g/ Yp �
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. .. . " ' IMPROVEMENT PERMIT For office useoniv
*CDP File Number 194972-1
0=.n Davie County Health Dep a r ' LED
210 Hospital Street County iDNumber.5707367216
, P.O.Box 848 �Iw Evaluated For: NEW
Mocksville NC 27028 Township:
Phone: 336-753-6780 Fax:336-753-1680 PERMIT VALID UNTIL: 7/8/2020
*NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit.
Applicant: Todd Josey Property owner: Larry Graham
Address: 226 Morrison Road Address: 173 Raintree Road
CRY: Mocksville City: Advance
StatefZip: NC 27028 StatefZip: NC 27006
Phone#: (336)596-2186 Phone#:
Property Location 8 Site Information
rddress/Road#: Subdivision: Phase: Lot:
idge Road
ocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 64 W to Ridge Road on left : Property on left
#of Bedrooms: 5 across from Smith Rd
#of People: 5
"Water Supply: NEW WELL
System Specifications
nitial S�,ste�m
Site Classification: Provisionally Suitable
Minimum TrenchDepth: a 4 Inches
Saprolite System? OYes QNo Maximum Trench Depth: 3 6 Inches
Design Flow: 6 0 0 Septic Tank:
1 a 5 0 Gallons
Soil Application Rate: 0 2 3 5 1-Piece: OYes @No
Pump Required: OYes QNo 0May_Be Required
*System Classification/Description:
TYPE II B.CONY.SYSTEM WITH 750 LINEAR FEET OF Pump Tank: Gallons
NITRIFICATION LINE OR LESS
*Proposed System: 251%REDUCTION 1-Piece: OYes ONo
Repair System Required:@ Yes ONo ONO, but has Available Space
r-SKe,
epair System
Classification: Provisionally Suitable Minimum Trench Depth: a 4 Inches
pplication Rate: 0 - a 7 5 Maximum Trench Depth: 3 6 Inches
*System Classification/Description: Pump Required: OYes +ONo O May be Required
TYPE II B.CONY.SYSTEM WITH 750 LINEAR FEET OF
NITRIFICATION LINE OR LESS
*Proposed System: 25%REDUCTION
Page 1 of 3
CDP File Number 194972- 1 County ID Number: 5707367216•
*Site Modifications ❑ Open Fill Sheet
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 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.
SitePlan The improvement Permit shall be valid for 6Years from date of issue with a site pian(means a drawing not necessarily drawn to
O scale that shows the existing and proposed property lines with dimensions,the location of thefaclitty and appurtenances,the
site forthe proposed Wastewater system,and the location of water supplies and surfacewaters).
Plat The Improvement Permit shall be valid without expiration with plat(means a properly surveyed prepared by a registered land
surveyor,drawn to a scale of one inch equals no morethan 60 feet,that includes the specific location of the proposed facility
0 and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters. Plat
also means,for subdivision lots approved by the local planning authority and recorded with the county register of deeds,a copy
of the recorded subdivisions plat that Is accompanied by a site plan that is drawn to scale).,
The Department and Local Health Department may impose conditions on the Issuance and may revoke the permits for failure of
the system to satistythe conditions,the rules,or this article.This permit Is subject to revocation If the site plan,plat;or Intended
use changes(NCGS 130A-335(1)).The person owning orcontrolling the system shad be responsible for assuring compliance
with the laws,rules,and permit conditions regarding system location,'Installation,operation,maintenance,monitoring,
reporting,and repair(.1838(b)).
Applicant/Legal Reps.Signature Required? OYes ONo
Applicant/Legal Reps.Signature: Date:
"issued By: 2140-Nations,Robert Date of Issue: 0 7 0 8 2 0 1 5
OValid without Expiration?
Authorized State Agent: O Create CA?
@Hand Drawing Olmport Drawing e
**Site Plan/Drawing attached.**
Page 2 of 3
IMPROVEMENT PERMIT 194972 - 1
Davie County Health Department CDP File Number:
210 Hospital Street 5707367216
P.O.Box 848 County File Number:
Mocksville NC 27028 Date:
()Inch
Drawing Drawing Type: Improvement ermit Sca ()Block
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IMPROVEMENT PERMIT
Davie County Health Department
210 Hospital street CDP File Number: 194972 - 9
P.O.BOX 848 5707367216
Mocksville NC 27028 County File Number:
Date: L02.,/ e8 / 2015
Click below to import an image from an external location:Drawing Type: Improvement Permit
<.• Type of i pplicatibn: V ew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IMPORTANT***THIS APPLICATION CANNOT. SSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the Elp V, BlILLETIN for instructions.
APPLICANT INFORMATION
_ 86 YS
Name to be Billed !cam Sps Gc/ Contact Person
Billing Address, o?a& invrr,son 2d Home Phone 336,- 594 -,,21S'4,
City/State/ZIP Muck�r: Ile NC a?oasl Business Phone
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged - 3` O 'S
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
(Permit is valid for 60 in nths with site plan,no expiration with complete plat.)
Owner's Name LCA Q �SZA Phone Number
Owner's Address .-d City/State/Zip MOAwcL 1(JC x700(�
Property Address ,i)re, ho-,d City na&%..<<�
Lot Size ;)�\\.e�,co Tax PIN# S 1 p`11,27'?16
Subdivision Xime(iapplicable) Section/Lot#
Directions To Site: (o4 �ZI$9jr, )Z-A-p- )>-;,go rm!. PPw �✓
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? ❑Yes RKo
Does the site contain jurisdictional wetlands? ❑Yes Gfo
Are there any easements or right-of-ways on the site? ❑Yes Cato
Is the site subject to approval by another public agency? ❑Yes 110
Will wastewater other than domestic sewage be generated? ❑Yes &Ko
IF RESIDENCE FILL OUT THE BOX BELOW
#People _ ,#Bedrooms #Bathrooms 3 Garden Tub/Whirlpool Eames ❑No
Basement: ❑Yes Rlqo Basement Plumbing: ❑Yes RTgo
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: ❑ County/City Water V'New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Y<O
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 hereby grant right of entry to the Authorized
Representative of the Dap1CHHealth Department to conduct necessary inspections to determine compliance with applicable
laws and rules. I undersresponsible for the proper identification and labeling of property lines and corners and
loc ing anHagg' orse/fa 'lity cation,proposed well location and the location of any other amenities.
Property owner's or owner's legal representative signature _ Site Revisit Charge
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All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the implied
warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie,
North Carolina,its agents,consultants,contractors or employees from any and all claims or causes of action due to or arising out of the use or
Inability to use the GIS data provided by this website.
:= ~" DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site-Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Ridge Road
Todd Josey 21.296 Acres
336 596-2186
7a7-3(�-7z.l -- --- - --- - - ------ ----
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring �it Cut
FACTORS 1 2 3 4 5 6 7.
Landscape position I
Slo e.%
HORIZON I DEPTH-
Texture group
Consistence
Structure I
Mineralogy
HORIZON R DEPTH
Texture group C
Consistence w
Structure yI
Mineralogy
HORIZON III DEPTH I
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS I
RESTRICTIVE HORIZON
SAPROLITE I
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE O- d•
SITE CLASSIFICATION: EVALUATION BY: !V�`k��Q
LONG-TERM ACCEPTANCE RATE: 7A OTHER(S)PRESE
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 lope
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 fim
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 bloccy
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralogy
1:1,21,Mixed
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 wi chroma 2 or less
Classification-S(suitable),PS(provisionally suitable),U(unsuitable)
LTAR-Long-term acceotance rate- sal/dav/ft2 TV-T.M ncinc