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139 Rumple Ln OPERATION PERMIT or fice use Only Davie County Health Department *CDP File Number 12289172 �- 210 Hospital Street E3-000-00-104.01 P.O. Box 848 County ID Number. Mocksville NC 27028 Evaluated For. NEW Phone:336-753-6780 Fax: 336-753-1680 Township: Applicant: Randall Foster rAddress, opertyowner. Randall Foster Address: 3228 US HWy 601 N 3228 US HWy 601 N City: Mocksville dy: Mocksville State2ip: NC 27028 StatefZip: NC 27028 Phone#: (336)3994672 Phone#: (336)3994672 Prol)erty Location & Site Information Address/Road#: '31k Subdivision: Phase: Lot: Rumple Lane Mocksville C 27028 Directions Structure: SINGLE FAMILY 601 North, Rumple Lane on right past Jolly Rd. on left #of Bedrooms: 3 #of People: 3 *Water Supply: NEW WELL *IP Issued by. *System Classification/Description: TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: SaproliteSystem? OYes QNo Design Flow: 3 6 0 GRAVITY-SERIAL Pump Required? Distribution Type: OYes QNo Soil Application Rate: 0 - 3 *Pre Treatment: Drain field Nitrification Field 1 a 0 0 Sq.ft. *System Type: INFILTRATOR OUICK 4 STANDARD No. Drain Lines 3 Installer: EncLakey Total Trench Length: 3 0 0 It. Certification#: 1106 Trench Spacing: — 9 Inches O.C. (+)Feet O.C. *EH S: 2140-Nations.Robert Trench Width: 3 Inches Feet Date: 1 1 / 1 9 / 2 0 1 4 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches 77) Minimum Soil Cover. 4 -Approval8tatus Inches Maximum Trench Depth: 3 6 Inches -® Approved Disapproved " Maximum Soil Cover: a 4 Inches CDP Fite Number 122891 - 2 Septic Tank County ID Number: 0-9oo-ao-104-01 Manufacturer. Shoaf Lat. ` : , STB: 760 Long Gallons: 1000 Installer. Eric lakey Certification#: 1106 Date: 0 ? l a i / a 0 1 4 *EHS: 2140-Nations.Robert *Filter Brand: POLYLOK PLA 22 With Pipe Adapter 1 9 a 0 1 ❑ Yes ❑ No ST Marker Date: Reinforced Tank: E] Yes 0 No Approval Status �ieTank ❑ Yes ® No =® Approved d Disapproved �,. Pump Tank Manufacturer Installer. PT: Certification#: Gallons: *EHS: _ Date: / / Date: RiserSealed ❑ Yes ❑ No ig . ❑ Yes ❑ N O ( �� A�" u RiserHe ht' Min.6 in.} pproust Stats Reinforced Tank: ❑ Yes - ❑ No ❑ Approved❑ Disapproved 1 Piece Tank: ❑ Yes ❑ NO Supply Line Pipe Size: inch diameter Installer Pipe Length: feet Certification 9: *Schedule: 'EHS: Pressure Rated ❑ Yes ❑ No Date: Approved fittings C1Yes ❑ NO r ApprovalStatus<�� :❑ Approved❑ Disapproved PLiMp Requirmenj Pump Type: Installer. Dosing Volume: - Gal Certification#: Draw Down: Inches *EHS: *Chain: Date: Valves Accessible ❑ Yes ❑ NO W Flow Adjustment Valve ❑ Yes ❑ No Check-valve ❑ Yes ❑ No ApprovalStatus PVC unions ❑ Yes ❑ No ❑.Approved C] Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ Yes 0 No CDP File Number' 122891 - 2 County ID Number: E3-000-M104-01 Electric Equipment NEMA4XBox or Equivalent ❑ Yes ❑ No Installer. Box 12 inches Above Grade ❑ Yes ❑ NO Certification#: Box Box Pump Tank ❑ Yes ❑ NO Conduit Sealed ❑ Yes ❑ No 'ENS: Pump Manually Operable ❑ Yes ❑ NO "Activation Method: Date:. Approval Status Alarm Audible ❑ Yes ❑ N o p Approved❑ Disapproved Alarm V�isible�� Yes ❑ NO 2140•Nations,Robert 'Operation Permit completed by: Authorized State Agent: Date of Issue: 1 1 / 1 9 / 2 0 1 4 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 TYPE U a sewage septic system. Rule.1961 requires that a Type TYPE II A septic system meet the following criteria: Minimum System Review ByThe Local Health Department: N/A Management Entity: OWNER Minimum System Inspection/Maintenance Frequency By Certified 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 entitywith a certified operatoror a private certified operator forthe life of the septic system. 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 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 formaintenance 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 01mport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT 122891 -2 Davie County Health Department CDP File Number: 210 Hospital Street E3-000-00-104-01 P.O.Box 848 County File Number: Mocksville NC 27028 Date: Q Inch Drawing DrawiN/A ng Type: Operation Permit / Scale: Q �L Q k � � ?a ii 1 I DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 OPERATION PERMIT Account #: 990006150 Tax PIN.EH#: E&MID-00-1104-01 Billed To: Randall Foster _ Subdivision Info: gq Reference Name: Location/Address: umple Lane-27028 Proposed Facility: Residence Property Size: 4 Ac ATC Number: 1.22q .1 **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 Tank Date Tank Size Pump Tank Size Bedrooms: System Installed By: Installer# Date: GPS Coordinate: 1 . Environmental Health Specialist Date: 11 DCHD 11/06(Revised) CONSTRUCTION For office use only • AUTHORIZATION 'CDP File Number 122891 - 1 Davie County Health Department County ID Number: E3-000.00-104.01 r210 Hospital Street Evaluated For: NEW P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone:336-753-6780 Fax:336-753-1680 0 9 / 1 8 2 0 1 8 Applicant: Randall Foster (Property Owner: Randall Foster Address: 3228 US Hwy601 N Address: 3228 US Hwy 601 N City: Mocksville o City: Mocksville State2ip: NC 27028 State/Zip: NC 27028 Phone;:: (336)492-5938 Phone (336)492-5938 Property Location & Site Information Address'Road ::: Subdivision: Phase: Lot: Rumple Lane Mocksville NC 27028 Directions Structure: SINGLE FAMILY 601 North, Rumple Lane on right past Jolly Rd. on left of Bedrooms: 33 of People: 3 'Water Supply: NE'+Y%',,ELL System Specifications t:tinimum Trench Depth: 2 4 Site Classification: PS Inches Minimum Soil Cover. Saprolite System? QYes ONo Inches Design Flow: 3 6 0 h1aximum Trench Deptti: 3 6 Inches Soil Application Rate: Maximum Soil Cover:0 3 Inches 'System Classification/Description: 'Distribution Type: GRAVITY-SERIAL TYPE If A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons 'Proposed System: 25°a REDUCTION 1-Piece: OYes ONo Pump Required: QYes ONo OMay Be Required Nitrification Field Sq. ft. Pump Tank: Gallons No. Drain Lines 1-Piece: QYes ONo Total Trench Length: 3 0 0 ft GPI.1—vs-- ft. TDH Trench Spacing: _ QInches O.C. QFeet O.C. Dosing Volume: Gallons Trench Width: Inches 8Feet Grease Trap: Gallons Aggregate Depth: . inches Pre-Treatment: ONSF OTS-1 OTS-II Septic Tank Installer Grade Level Required: 01 Oil 0111 OIV Page 1 of 3 CDP File Number 122891 -'1 ' County ID Number: E3-000-00-104-01 ❑ Open Pump System Sheet Repair System Required:OYes ONo ONo, but has Available Space epair System Trench Spacing: Q Inches O.C. 'Site Classification: Ps o Feet O.C. Trench Width: Q Inches Design Flow: 3 6 0 — o Feet Soil Application Rate: 0 Aggregate Depth:- 3 inches 'System Classification/Description: Minimum Trench Depth: 2 4 Inches TYPE II A.CO..W SYSTEM(SINGLE-FAh1ILY OR 480 GPD OR LESS) f linimum Soil Cover. Inches Maximum Trench Depth: 3 6 Inches 'Proposed System: 25'oREDUCTION Maximum Soil Cover: Nitrification Field Inches Sq. ft. No. Drain Lines 'Distribution Type: GRAVITY-SERIAL Total Trench Length: 3 0 0 ft Pump Required: Oyes ONo OF-Iay Be Required Pre-Treatment: ONSF OTS-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 no way 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 Construction shall be valid fora person equal to the period of validity of the Improvement Permit,not to exceed five years,and may be issued at the sametime the Improvement Permit Issued(NCGS 13OA-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 Authorization is found to have been Incorrect,falsified or changed,or the site is altered,the permit or Construction Authorization shall become invalid,and may be suspended or revoked(.1937(g)).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: 2244-Daywalt,Andrew Date of Issue: 0 9 1 8 2 0 1 3 Authorized State Agent: faalfunction Log Oyes OHand Drawing Olmport Drawing Total Time:(H H-111.1) **Site Plan/Drawing attached.** 0 1 Hours 0 0 t.i inutes Page 2 of 3 S-8-CNS issued-new CONSTRUCTION AUTHORIZATION 122891 - 1 . Davie County Health.Uepartment CDP File Number: • •• 210 Hospital Street • � P.O.Box 848 County File Number: E3-000-00-1041-01 Mocksville NC 27028 Date: 0 9 / 1 8 / 2 0 1 3 Olnch Di=awing Drawing Type: Construction Authorizatio I Scale: . OONA = ft. ON/ 7 i 1 I 10` 1 . ���e . Pana 3 of 3 IMPROVEMENT PERMIT , For Office Use o Davie County Health Department 'CDP File Number 122891 - County ID Number:E3-000-00-7104-01 V 4 210,Hospital Street P.O.Box 848 Evaluated For. NEW Mocksville NC 27028Township. Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID U11TIL: 8/30/2018 'NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. r pplicant: Randall Foster Property Owner. Randall Foster ddress: 3228 US Hwy 601 N Address: 3228 US Hwy 601 N dY: Mocksville Cay: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 Phone»: (336)492-5938 Phone;:: (336)492-5938 PropertV Location & Site Information Address/Road »: Subdivision: Phase: Lot: Rumple Lane Mocksville NC 27028 Directions Structure: SINGLE FAMILY 601 North, Rumple Lane on right past Jolly Rd. on of Bedrooms: 3: left »of People: 3 'Water Supply: NBVMLL S stem Specifications Willa/ S stem 'Site Classification: PS I.linimum Trench Depth: 2 4 Inches Saprolite System? QYes QNo Maximurn Trench Depth: 3 6 Inches Design Flow: 3 6 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 0 . 3 1-Piece: QYes QNo 'System Classification/Description: Pump Required: QYes ONO OIAay Be Required TYPE It A.CONY SYSTEM(SINGLE-FA.%IILY OR 480 GPD OR Pump Tank: Gallons LESS) *Proposed System: 254bREDUCTION 1-Piece: QYes QNo Repair System Required:QYes ONO QNo, but has Available Space Repair System Rm "Site Classification: PS Minimum Trench Depth: 2 4 Inches Soil Application Rate: 0 - 3 Maximum Trench Depth: 3 6 Inches Pump Required: No .1a be 'System CClassification/Description: Yes Q Required 1 Q � Y TYPE II A.CONY SYSTEP.1(SINGLE-F&MILY OR 480 GPD OR LESS) 'Proposed System: 250,b REDUCTION Pagel of 3 CDP File Number-•122891 ' 1. County ID Number: E3-000-00-104-01 *Site Modifications Q 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 no way guarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. Site Plan The Improvement Permit shall be valid for 5 years from date of issue with a site plan(means a drawing not necessarily drawn to O scale that shows the existing and proposed property lines with dimensions,the location of the facility and appurtenances,the site for the proposed wastewater system,and the location of water supplies and surface waters). Plat The Improvement Permit shall be valid without expiration with plat(means a property 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 O 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 satisfy the conditions,the rules,or this article This pennit Is subject to revocation if the site plan,plat,or intended use changes(NCGS 130A-335(f)).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: 2244-Daywalt.Andrew Date of Issue: 0 8 / 3 0 / 2 0 1 3 Authorized State Agent: OValid without Expiration? 0Create CA? 01-land Drawing Olmport Drawing **Site Plan/Drawing attached.** Total Time:(HH:L1t.t) 0 1 Hours 0 0 Minutes Page 2 of 3 Activitv Code: S4-IRS issued:new,valid for 60 mos. IMPROVEMENT PERMIT 122891 - 1 Davie County Health fPepartment CDP File Number: ` 210 Hospital Street E3-000-00-104.01 P.O.Box 848 County File Number: hlocksville NC 27028 Date: / Oinch Drawing Drawing Type: Improvement Permit Scale: . OBlock ON/A ft. C01570 I 4r 10 s eph -71Y 3a3 i v Page 3 of 3 i •'0�-. APPLICATION FOR SITE EVALUATIONANTROVENIENT JERNIIT & ATC PAID - Davie County Environmental Health Date: g'lq-13 P.O.Bog 848/210 Hospital Street Am g Mocksville,NC 27028 Recelvedb : (336)753-6780/Fax(336)753-168 l.h�t Application For: Site Evaluation/Improvement Permit VAuthorization To ons (ATC) ❑ Both Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Mo cation of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPT;TCANT TNFORMATTON Name [ lT Contact Person M Address,�Z-1M< W � (0 0/ Home Phone City/State/ZIP C BusinessPhone Name on Permit/ATC if Different than Above Mailing Address S W City/State/Zip PROPERTY INFORMATION *Date House/Facility Comers Flagged NOTE:_ A survey plat or site plan must accompany this application. Included: ❑ Site.Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no ex Fation with complete plat.) Owner's Name-19%;m) AL-k., 'L, A a6ul a� E4=9— Phone Number 492,- SSI �— Owner's Address ?22 CJS t}W%4. (00( ...City/State/Zip M�$\j I Property Address Ro"plz LAN L ,_ City MQC Lot Size A,l(ICV i-5 Tax PIN# Subdivision Name(if applicable) Section/Lot# 'db0"b0"l0�-r7 Directions To Site: ONP JnQ51 Y If the answer to any of the following questions is"Yes",supporting doc entation must be attached: Are there any existing wastewater systems on the site? Yes No Does the site contain jurisdictional wetlands? Yes No Are there any easements or right-of-ways on the site? 1'es No Is the site subj ect to approval by another public agency? _Yes�-RNo Will wastewater other than domestic sewage be generated? Yes No TF RF,STDF,NC,F,FTT.T,01 JT T1iF,BOX BFLOW #People #Bedrooms -:�— #Bathrooms ` Garden Tub/Whirlpool es ❑No Basement:1<Yes ❑No Basement Plumbing: ❑YesXNo 7F NON-``R`ESTDF,NC:F,FIT OUT THE BOX.BFJ OW 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:AConventional, ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City.Water Vew Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?-a Yes io 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 Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and comers and locating and flagging or s g the ous facility loc ' n w 1 location and the location of any other amenities. Property o er's or owner's legal representative signature Site Revisit Charge Date(s): Client Notification Date: Date EHS: c'5o Sign given ❑Yes ❑No Account# Revised 11/06 Invoice# _ - - sr _ 1 _ r; fi - :- 0 c, di Cn a' C6 4' O 4 N c", BOBBY R. JONES I D.B. 88 , PG. 105 I BOBBY R. JONES D.B. 126 , PG. 295 I D.B. 88 , PG. 105 I ( I D.B. 126 , PG. 295 I 1 I existing iron ( I existing _� iron , new ion TOTAL 538.20 S 86*58'25& E eXirong i 253,92 515.28 22.92 cn PIN 5821026712 ' 1 10' 3 ai 0. W SHOUSE > W J TRACT 1 co e3 AREA= 2.1095 AC. "' ]D ° �' Q�. > 100 8 �1 — t AREA= 4.109 AC. ^;� I o CHRISTOPHER BARRETT ti 8 V) • ,� PL.BS. to, PG. 180 Z A A.B. 897, PG. 875 NEW 30' EASEMENT AS OF 6/17/2013 (TIE) �l S 87 ' 8' E � EXISTING',30', EASEMENT NEW 30' EASEMENT AS OF 6/17/201 I / — _----- - ------ — - -- �-- /_-�- TOTAL= 508,92 '_'_`---"""—.1.,,,. "' N 87.04'48' V cXiroing . existing 492.43 iron 16.49 tin I ——— o ———— existing RUMPLE LANE — �-- I iron SEE D.i3. 766, PG. 619 FOR EXISTING 30' EASEMENT JORDAN LOWS 15 , PG. 327 z 1 I I I HARD _. --- existing 2 I I I D.B. 1 — DWIGHT F. RUMPLE I I I M -- D.B. 4 , PG. 7 -------- I 1 D.B. 1622,, PG. 269 � i I ,• t DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION �3-oQa o6-l0�-ol 3Zzg us gwy 601/ Water Supply: On-Site Well 31 Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope% 17• HORIZON I DEPTH dr Texture group Consistence Structure Mineralogy 71 I.' HORIZON II DEPTH - 2. Texture groupe Consistence Structure Mineralogy , HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION t� LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: f EVALUATION BY: �J LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: 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 slope Textiire 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, Moos> VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm 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 blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogy 1:1,2:1,Mixed Notes ' 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 with chroma 2 of less Classification-S(suitable),PS(provisionally suitable),U(unsuitable) T TAR -T nnv-term arrantnnra rata_ oal/Anu/ft7 r�nrrr�neine m__:•_ ,.