183 Shutt RdOPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753.1680
Applicant: Herman Myers and Ken Myers
Address: 183 Shutt Road
City: Advance
State2ip: NC 27006
Phone #: 368-28496
Address/Road #: Subdivision:
183 Shutt Road
Advance NC 27006
Structure: SINGLE FAMILY
# of Bedrooms: 2
# of People:
*Water Supply: NIA
*CDP File Number 158788-1
County ID Number:
Evaluated For: REPAIR
�ownship:
Property owner: Herman Myers and Ken Myers
Address: 183 Shutt Road
City: Advance
State/Zip: NC 27006
11"p—lone #: 368-28496
& S
Phase: Lot:
Directions
Hwy 64 East left on hwy 801 , go approx. 4miles
Shutt Road on right after Ellis School
*IP Issued by. *System Classification/Description:
TYPE 11 A CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by: 2140- Nations, Robert
Saprolite System? QYes QNo
Design Flow: a 4 0 * GRAVITY -SERIAL Pump Required?
Distribution Type: QYes (DNo
Soil Application Rate: 0 . 3 *Pre Treatment:
Drain field
Nitrification Field
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Aggregate Depth:
8 0 0 Sq. ft.
3
a 0 0 ft -
()Inches O.C.
Feet O.C.
3 Inches
&Feet
inches
*System Type: INFILTRATOR QUICK 4 STANDARD
Installer: Jarnei Barnes
Certification #: 1018
*EH S: 2140 - Nations. Robert
Date: 1 a/ 0 1/ a 0 1 4
Minimum Trench Depth: 3 6
Inches
Minimum Soil Cover. a 4 Inches Approval Status
Maximum Trench Depth. 3 6 Inches FIMEprovedD Disapproved
Maximum Soil Cover: a 4 Inches
CDP File Number 158788-1 County ID Number:
SeptlC TanK
r
Manufacturer. Lat.
Long:
STB: -
Gallons: Installer:
Date:
/
/
Certification #:
Yes
❑
NO
'
*EHS:
*Filter Brand:
No (Min.6 in.)
einforced Tank: ❑
Yes
❑
ST Marker:
❑Yes
❑
No
Date:
nforced Tank:
❑Yes
❑
NO
No
Approval Status
❑ Approved ❑ Disapproved
Vent Hole
❑ Yes
❑
No
❑ Approved ❑ Disapproved
1 Piece Tank:
❑ Yes
❑
NO
Pump Tank
Manufacturer.
PT:
Gallons:
Date:
/
/
Riser Sealed ❑
Yes
❑
NO
Riser Height: ❑
Yes
❑
No (Min.6 in.)
einforced Tank: ❑
Yes
❑
No
, 1 Piece Tank: ❑
Yes
❑
NO
Pipe Size: inch diameter
Pipe Length: feet
*Schedule:
Pressure Rated ❑ Yes ❑ No
Approved fittings ❑ Yes ❑ No
Installer:
Certification #:
*EH S:
Date:
Approval Status
❑ Approved ❑ Disapproved
upply Line
Installer:
Certification #:
*EHS:
Date:10
Approval Status
O Approved ❑ Disapproved
J
/ Pump Type: Installer:
Dosing Volume: — Gal Certification #:
Draw Down: Inches *ENS:
*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
❑
No
CDP, File Number 158188 -1
NEMA 4X Box or Equivalent
Box 12 inches Above Grade
Box Adj. To Pump Tank
Conduit Sealed
Pump Manually Operable
*Activation Method:
County ID Number:
Approval Status
Alarm Audible El Yes ElNo ❑ Approved ❑ Disapproved
Alarm Visible ❑ Yes ❑ No
2140 • Nations. Robert
*Operation Permit completed by.
Authorized State Agent:
Owner/Applicant Signature:
Date of issue: 1 a/ 0 1/ a 0 1 4
This system has been installed incompliance 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 a A. sewage septic system.
Rule .1961 requires that a Type TYPE 11 A septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: WA
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency ByCertified Operator:
NSA
Reporting Frequency By Certified Operator: NIA
Rule .1961 requires that a Type IV and V septic systems designed for a 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 for a 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 owner and 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.**
Electric Equipment
❑
Yes
❑
No
Instauer:
❑
Yes
❑
No
Certification 9:
❑
Yes
❑
No
❑
Yes
❑
No
*EHS:
❑
Yes
❑
N o
Date:
Approval Status
Alarm Audible El Yes ElNo ❑ Approved ❑ Disapproved
Alarm Visible ❑ Yes ❑ No
2140 • Nations. Robert
*Operation Permit completed by.
Authorized State Agent:
Owner/Applicant Signature:
Date of issue: 1 a/ 0 1/ a 0 1 4
This system has been installed incompliance 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 a A. sewage septic system.
Rule .1961 requires that a Type TYPE 11 A septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: WA
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency ByCertified Operator:
NSA
Reporting Frequency By Certified Operator: NIA
Rule .1961 requires that a Type IV and V septic systems designed for a 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 for a 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 owner and 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
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
CDP File Number: 158788' 1
County File Number:
Date: /
Q Inch
Scale: OBlock
QN/A
.�_...
CONSTRUCTION
AUTHORIZATION
.sr w Fti`t mow.
.E+r 3s Davie County Health Department
si 210 Hospital Street
:x r Yr
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Herman Myers and Ken Myers
Address: 183 Shutt Road
City: Advance
State/Zip: NC 27006
Phone #: 368-28496
Address/Road #: Subdivision:
18.3 Shutt Road
Advance NC 27006
Structure: SINGLE FAMILY
# of Bedrooms: 2
# of People:
*Water Supply: N/A
/1, For Office Use Only
*CDP File Number 158788 -1
County ID Number.
Evaluated For. REPAIR
�, Township:
PERMIT VALID UNTIL:
10/aa/a019
Property Owner. Herman Myers and Ken Myers
Address: 183 Shutt Road
City: Advance
State/Zip: NC 27006
Phone #: 368-28496
Phase: Lot:
Directions
Hwy 64 East left on hwy 801 , go approx. 4miles Shutt
Road on right after Ellis School
m Soecifications
/Site
Trench Depth:
a
4 Inches
\
te CIBSSIfCatlOn: Provisionally Suitable
Minimum Soil Cover:
1
a
Saprolite System? O Yes 9 No
Inches
Design Flow: a 4 0
Maximum Trench Depth:
3
6 Inches
Soil Application Rate: 0 3
Maximum Soil Cover.
a
4 Inches
*System Classification/Description:
*Distribution Type:
GRAVITY -SERIAL
TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
S t' -Ir- k'
*Proposed System: 25% REDUCTION
Nitrification Field
No. Drain Lines
Total Trench Length
Trench Spacing:
Trench Width:
Aggregate Depth:
'upIc n . Gallons
1 -Piece: O Yes O No
Pump Required: O Yes O No O May Be Required
8 0 0 Sq. ft. Pump Tank: Gallons
a 1-Piece:OYes ONo
a 0 0 ft, GPM—vs— ft. TDH
9 R Inches O.C. —
Feet O.C. Dosing Volume: Gallons
3 Olnches
® Feet Grease Trap: Gallons
inches Pre -Treatment: O NSF OTS -I O TS -I I /
Septic Tank Installer Grade Level Required: 01 O I I 0111 ON
Page 1 of 3
CDP File Number 158788 - 1
*Site Classification:
Design Flow:
Soil Application Rate:
*System Classification/Description:
*Proposed System:
Nitrification Field
No. Drain Lines
County ID Number:
❑ Open Pump System Sheet
OYes O No (9 No, but has Available
Trench Spacing:
O Inches O.
– O Feet O.C.
Trench Width:
Inches
8Feet
Aggregate Depth:
inches
Minimum Trench Depth:
Inches
Minimum Soil Cover:
Inches
Maximum Trench Depth:
Inches
Maximum Soil Cover:
Inches
Sq. ft.
*Distribution Type:
Total Trench Length: ft Pump Required: OYes ONo OMay Be Required
� Pre -Treatment: O NSF OTS -1 OTS -11
*Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. Ramey, 9
750
*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. n...m'o
2000
This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit, not
to exceed five years, and may be issued at the same time 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
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: 2140 - Nations, Robert Date of Issue: 1 0 a s 2 0 1 4
Authorized State Agent: `""4-�;005� —� Malfunction Log Oyes
9 Hand Drawing O Import Drawing
**Site Plan/Drawing 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
1154`
3
o.
CDP File Number: 158788 - 1
County File Number:
Date: 10 / a a/ a 0 1 4
O Inch
Scale: O Block
O N/A
Uv
6
V G,
Page 3 of 3
P1. P2