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195 Sugar Creek Rd t � t�PERATIC�N PECtMIT or �ce se n v �sr�. Davie County Health Department *CDP File Number 201767-1 � 210 Hospital Street , � � p.�.6flX g4g County ID Number. �'`=���'` Mocksville NC 2742$ Evaluated�or. REPAiR Phone:336-753-6780 Fax:336-753-1680 Tovrnship: Appiicant: E. Diane Foster Prop�rty Owner: E. Diane Foster Address: Z�0 Magnolia Ave Address: 250 Magnalia Ave ��Y� Mocksvilie ��Y� MocksviUe State2ip: NC 27I?2$ Stafe/Zip: NC 2702$ Phane�: Phone#: Pro e Loca#ion � Site information AddresslRoad#: Subdivision: Phase: Lot: 195 Sugar Creek Rd Mocksville NC 27028 Dlrections Stnicture: SINGLE FAMILY Hwy 158, left Farmington Rd. cross Hwy 801 to Gilbert Rd on !eft to Sugar Creek #of Bedmoms. 4 #of People: 'Watet Supply: EXtSTING WELI *IP Issued by. *System Ctassificatan/Description: 'TYPE 111 B.SYSTEM WlSINGLE EFFLUEM'PUMP •CA issued by: 2�a0»tyations,Ropert SaproliteSystem7 QYes QNo Design Flow: 4 $ � * F�1MP TO GRAVI7Y Pump Requ�red? DistributionType: �jY�s QNo Soil Application Rate: � � a *p�e T�eatment: Drain field Ndrification Field a 4 � � S4•�• *System Type: �N�fL'1'f�TORQUICKa StANOARD No. Orain Lines 4 Instape�: ShermanDunn .___.�_� Total Trench Le�gth: 5 0 0 �. Certification#: ��02 Trench Spacing: _ 9 Q�nches O.C. .. - Q Feet O.C. "EH S: 2tao•Nauons,aobert Trench Width: 3 Inches , — �Feet Date: � a / a 6 / a � Y 6 ....._...r. � - , Aggregate Oepth: inches Minimum T�ench Depth: 3 6 Inches Minimum Soil Caver. a � Apprcrtal Status ` Inches Maximum Tr�nch Depth: 3 6 p `Approved� Disapproved ; .; ; Inches Maximum Soil Caver. a 4 tnches CDP Fite Number 2417fi7 - 1 County ID Number:• � r T Se tic Ta�nk Manufacturer. Lat. � Long: STB: � Gailons: insta�er. Date: � � Certification#: ' '" 'EH S: *Fitte�Brand: ST Marker. ❑ Y�5 ❑ NO Date: � � _ ReinforcedTank: ❑ YeS ❑ No � ; � - Approv�tSt�tus � t Piece Tank: O Yes ❑ No � C� Ap�rove`d� D�sapproved � Pump Tank Manufacturer. Snoaf Instaqer. sherman ounn pT: �3 CertificaGon#: 2�02 Gallons: �250 *EHS: 21ao•Nat�a,s,Robert - Date: 1 1 / 1 4 / a 0 1 5 Date: 0 4 / � 6 / � 0 1 6 RiserSeaied Q Y�s ❑ No RiserHeght: � Y�S ❑ NO (Min.�6 in.) ` � �.Approv8lSfe�us �� �� :� einforced Tank: ❑ Yes CI No � p q �� roved�7 Disa roved���� � I3 Yes ❑ Na PP PP. � 1 Risce Tank: --� Suppiy l.ine - - Pipe Size: a inch diameter InstaAer. Sherman dunn �, Pipe Length: 3 � {� feet CertificaGon#: 27�2 "Schedule: �� *EH S: 2�ao-n�auor�s,�rt Pressure Rated O Ye5 ❑ No Date: � 4 / a b l a 0 1 6 Appraved fittings � Y@S ❑ NO � �App�orraiStatus �� �I Approv�d❑ Disa�ppiroved . � � r Pump Type: z��er Instaqer. Sherman Ounn Dosing Volume: — Ga� Certification#: 2�02 Draw Down: (�CheS 'EHS: 2140-Natiortis,Robert "Chain: STaNt,�ss � 4 / a 6 / a 0 1 6 D�te: Valves Accessibie p Yes ❑ NO FlowAdjustmentvaive � Y8s ❑ No check-van►e C1 Yes I� No Approva!status Pvc unions Q Yes C7 No = CI Approved Cl"D�sapproved , Vent Hote Q Yes ❑ No ` Anti-siphon Hole Q YeS ❑ No CbP File Numbzr 241.76� - � County ID Number: Electric E uI ment N EMA 4X Box ar Equivatent [p Yes ❑ N 0 Instaqer, Sherman Dunn Box 12 inches Above Grade Q Yes ❑ No ��p2 Certibcation#: 8ox Adj.To Pump Tank Q Y�S ❑ N 0 Conduit Sealed � YeS ❑ N o "`EM S; 2140•Nations,Robert Pump ManuallyOperable p Yes ❑ NO "Acfivatinn Method:p���ygp�� Date: � . 4 / a 6 / a 0 1 6 Approval St�tus,, . ��am,Aud�b� � � Yes O No � �� �� � � = [`� Approved O Disapproved `� �� AIaRn visible � Yes O No ��aa•r���o�s.ao�e�t *Operation Permit compieted by: - Authorized State Agent:�� � Date nf issue: � 4 / a 6 / a 0 1 6 OwneriApplicant Signatu�e: _This system has been installed in compliance with applicable NC General Statutes:Article 1 i, Chapter 130A, Rules for Sewage T�eatment and Disposal�15A NCAC 18A .1900 et. Seq..and all conditions of the Impr�vament PeRnit and Const�uction Author¢ation.This praperty is senred by a TYpE In�. sewage sepiic system. Rule.1961 requires that a Type TM�'E����. septic system meet the following criteria: - M�nimum System Review ByThe Local Neatth Department: 5��• Management Entity: OWNER M�imum System Inspectionnvlaintenance Frequency ByCertified �peratnr: WA Reporting Frequency By Certified Operatar.�A Rule.1961 requires that a Type IV and V septic systems designed fora home/business awner must maintain a vatid contract w�h a public management entity with a certified operator or a private certified operator forthe life of the septic system, Rule .1961 �equires that Type VI septic systems designed fora homelbusiness awne�must maintain a valid contract with a public management entitywith a certified operatoc for the life of the septic sysfem. Rule. 1961 (2)(e)requires a contract shall be executed between the system owner and a management entRy prior to the issuance of an Operation Permit t'or a system required ta be maintained by a pubGc or private management ent�y, uNess the system ownerand certified operator are the same. The contract shall require specif�c requirements for maintenance and operation, responsib�ities of the owner and systems operator,provisions that the contract shatl be in effect for as�ng as the system is in use,and ather requirements for the continued proper pertormance of the system. tt sha11 also be a cond�i�n nf the Operation Permit that subsequent owners af the systems execute such a cont�act. �Hand arawing 4lmport Drawing **Site Plan/Qrawing attached.** �'� f OPERATION PERMIT ' 20�767 -9 Davie Caunty Heatth Department CDP File Number: 21U Hospitai Street P.o.aoxsas County File Number: Mocksvdte Nc 2�028 Date: / 1 4 V...4.�L..i�./ Q InCh Dra�v n Drawing Type: Operation Permit Scale: . , , pB ck = ft. oN� ; , ��� � �, �-� .� ,� � I � _. 44` r t""s � � , , � � _. �� � � � �� _ _ �-'�--� .�.�� . .�'�` i _ .__ ___ , ��' . �� p � I 1_ ��_ _ - . e � 3� � � �� � , � ^ � � � � � � ..�k ... ... �� � .,�.:_+� _ , ' ...... `�' c� .�'c-�� _ � �i � �� �_ ._ .�.�.. _ _ _ .._.�.._._ � � � 1 j� � I � ,� ---�-- --- :_ _-- __� � � I ' "---�::� � � f� ��r��� � �{ � `� � . . ...�..�...�. [ � � ��a �I 1 � /.� 3 � �---_ _I -- c� � r ,� ��-�- , I I � �� � � � , r,..�.. -� , ..�._�. � __�E_�__ � _ � � �1 � � � � � �- � � ~ ..�i � �; � � � � i .�.._ —� �=.o .�.� I --�� � � .� `--- , � � � � � � ' ` CONSTRUCTION For o�ice use on�v � � '`CDP File Number ' 201767- 1 ,- AUTHORIZATION ��-'"'�'� Davie County Health Department County ID Number: � -. � 210 Hospital Street E'valuated For. REPAIR � P.O. Box 848 ' •�.�....o` Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax: 336-753-1680 0 3 / 1 5 / a 0 a 1 Applicant: E. Diane Foster Property Owner: E. Diane Foster Address: 250 Magnolia Ave Address: 250 Magnolia Ave City: Mocksville City: Mocksville State2ip: NC 27028 State/Zip: NC 27028 Phone#: Phone#: Propertv Location & Site Information Address/Road#: Subdivision: Phase: Lot: 195 Sugar Creek Rd Mocksville � NC 27028 Directions Stn,cture: SINGLE FAMILY Hwy 158, left Farmington Rd. cross Hwy 801 to Gilbert Rd on'left to Sugar Creek #of Bedrooms: 4 #of People: *Water Supply: EXISTING WELL - Svstem Specifications - Minimum Trench Depth: a ,4, Site Classification: Provis�onany su�tabie Inches Minimum Soil Cover: Saprolite System? O Yes �No 1 a Inches Design Flow: 4 $ 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: � , a Maximum Soil Cover: a 4 Inches "System Classification/Description: *Distribution Type: PUMP TO GRAVITY TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Septic Tank: Gallons `Proposed System: 2s%REDUCTION 1-Piece: �Yes O No Pump Required: Q Yes Q No Q May Be Required Nitrification Field a 4 0 0 Sq.ft. Pump Tank: 1 0 0 � Gallons No. Drain Lines 6 1-Piece: (�Yes �No Total Trench Length: 6 0 0 ft, GPM--vs— ft. TDH Trench Spacing: Inches O.C. — 9 Feet O.C. Dosing Volume: Gallons Trench Width: _ 3 �Inches Feet Grease Trap: Gallons Aggregate Depth: inches Pre-Treatment: O NSF OTS-I O TS-II Septic Tank Installer Grade Level Required: �I 011 �III �IV Page 1 of 3 � CDP File Number 201767 - 1 County ID Number: , . � Y, ❑ Open Pump System Sheet ' Re air System Required:�Yes O No O No, but has Available Space Repair Svstem Trench Spacing: g �Inches O. . *Site Classification: Provisionauy suitabie — Feet O.C. Trench Width: �Inches Design Flow: 4 $ � _ 3 Feet Aggregate Depth: Soil Application Rate: 0 . � inches � Minimum Trench Depth: a 4 Inches "System Classification/Description: TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Minimum Soil Cover: 1 a Inches Maximum Trench Depth: 3 6 Inches *Proposed System: 2s%REDUCTION Maximum Soil Cover: a 4 Nitrification Field a 4 0 0 Inches Sq.ft. No. Drain Lines 6 '`Distribution Type: PUMP To��viN Total Trench Length: 6 � � ft :Pump Required: �Yes Q No Q May Be Required Pre-Treatment: O NSF 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. R�N;� 750 *Permit Conditions The issuance of this permit by the Health Depa�tment in no way guarantees the issuance of other permits.The permit holder is responsible for checking with appropriate goveming bodies in meeting their requirements. R m�,;� 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,falslfied or changed,or the site is altered,the permit or Constructlon 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? O Yes �No ApplicanULegal Reps. Signature� Date: � � *Issued By: 2�40-Nations,Robert Date of Issue: � 3 / 1 5 / a 0 1 6 Authorized StateAgent:_ Malfunction Log OYes ;��;�~.- �Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 , ' � CONSTRUCTION AUTHORIZATION 201767 - 1 � . Davie County Heaith Department CDP File Number: �. 210 Hospital Street P.O.Box 848 County File Number: Mocksville rvc 2�o2a Date: 0 3 / 1 5 / a 0 1 6 D lnch Dr win Drawing Type: Construction Authorization Scale: . , O B�ock = ,ft. �N/A ............................................................ .................... �..........................._..............................................,................................................ � 1 , . .. .. : . . ' � ' . . . . ... , . ...... .... . , . - . .,g�� l . . 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CONSTRUCTION AUTHORIZATION . • � ' ' Davie County Health Department +"•* 210 Hospital Street CDP File Number: 201767 - 1 P.O.Box 848 Mocksville Nc 2�o2s County File Number: Date: .�.3./.1.5.'/.�_0.1.6. C ick below to import an image from_an external location: Drawing Type:Construction Authori tio �,_-----�--- �� , I �_ � r� -I � 1 � ,� �X�` � �"� a�� � ,�' ��'� �3 � -��. � � �� 3�', � _------ � ,N A� �� .. _ �� � � 5 � �� � �- � .� ` � � - � � � . , � W � , Page 3 of 3 P1 P2 � �'' � - ' CONSTRUCTION For office use on�v AUTHORIZATION *CDP File Number 201767- 1 �%�' Davie Count Health De artment ,,,y ''c� Y P County ID Number: � ' � 210 Hospital Street Evatuated For: REPAIR � P.O. Box 848 .�a.,.•�` :Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax: 336-753-1680 0 3 / 1 5 / a 0 a 1 Applicant: E. Diane Foster Property Owner: E. Diane Foster Address: 250 Magnolia Ave Address: 250 Magnolia Ave City: Mocksville City: Mocksville State2ip: NC 27028 State/Zip: NC 27028 Phone#: Phone#: Propertv Location & Site Information Address/Road#: Subdivision: Phase: Lot: 195 Sugar Creek Rd Mocksville NC 27028 Directions Structure: SINGLE FAMILY : Hwy 158, left Farmington Rd. cross Hwy 801 to Gilbert Rd on left to Sugar Creek #of Bedrooms: 4 #of People: "Water Supply: EXISTING WELL System Specifications Minimum Trench Depth: a 4 Site ClassifiCation: Provisionally suitable Inches Minimum Soil Cover: 1 a Inches Saprolite System? O Yes �No Design Flow: 4 8 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 . � Maximum Soil Cover: � 4 Inches "System Classification/Description: "Distribution Type: PUMP To��vinr TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Septic Tank: Gallons `Proposed System: 25%REDUCTION 1-Piece: O Yes �No Pump Required: Q Yes Q No Q May Be Required Nitrification Field a L�. Qj QJ Sq.ft. Pump Tank: 1 � 0 0 Gallons No. Drain Lines 6 1-Piece: �Yes ONo Total Trench Length: 6 0 � ft GPM--vs— ft. TDH Trench Spacing: Inches O.C. — 9 Feet O.C. Dosing Volume: Gallons Trench Width: _ 3 O Inches l�Feet Grease Trap: Gallons Aggregate Depth: inches Pre-Treatment: O NSF OTS-I O TS-II Septic Tank Installer Grade Level Required: O I O II O I II O IV Page 1 of 3 CDP File Number 201767 - 1 County ID Number: ' � � � ❑ Open Pump System Sheet Repair System Required:�Yes O No O No, but has Available Space Repair System Trench Spacing: 9 Inches O. . `Slte CIeSSIflCatlOft: Provisionally Suitable — �Feet O.C. Trench Width: �Inches Design Flow: 4 8 � _ 3 Feet Aggregate Depth: Soil Application Rate: 0 , a inches � Minimum Trench Depth: a 4, Inches `System Classification/Description: TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Minimum Soil Cover: 1 � Inches Maximum Trench Depth: 3 6 Inches "Proposed System: 25%REDUCTION Maximum Soil Cover: � 4 Nitrification Field a 4 0 0 Inches Sq.ft. No. Drain Lines 6 "Distribution Type: PUMP ro�w4viN Total Trench Length: 6 � � ft Pump Required: �Yes Q No Q May Be Required Pre-Treatment: O NSF 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. R�&� 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 goveming bodies in meeting their requirements. R�,�,� 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 Permlt 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 �NO Applicant/Legal Reps. Signature� Date: � � "ISSU2d By: 2�40-Nations,Robert Date of Issue: 0 3 / 1 5 / a 0 1 6 Authorized State Agent: Malfunction Log OYes -, ��, �Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 •. � � . , CONSTRUCTION AUTHORIZATION 201767 - 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville rvc 2�o2s Date: 0 3 / 1 5 / a 0 1 6 �Inch Dr win Drawin T e: Construction Authorization Scale: , . . O Biock = , .ft. 9 YP Q N/A . _...._.. .................................. .. ..........�................�............. ...... 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I � � ( ; i � I � � � ( � I � i i � ' � I. _ � r � .....� i � i � _ , � � � S'� � o � C;r .�-t � � ��I I ! � _�.. ...... ......... .. , . ....... .. . . _ ,. , �. : �.. _ � � ( I ' ' i i � I � : , � , � . _,_ � _ . ._ � l � l a . , l _ __! � . E .. Page 3 of 3 P1 P2 CONSTRUCTION AUTHORIZATION ' i � � Davie County Health Department 210 Hospital Street CDP File Number: 201767 - 1 P.O.Box 848 Mocksville NC z�o2a County File Number: Date: .�.3./.1.5. /.a.0.1.6. Click below to import an image from an external location: Drawing Type: Construction Authorization Page 3 of 3 P1 P2 __ .. ,. , , -�- DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section � Soil/Site Evaluation � APPLICANT INFORMATION PROPERTY INFORMATION — � ( F� ... � ' � � , � u � � �� � �� � � h s � Water Su 1 : On- ite Well� �� ni ' pp y S Commu ty Pubhc Evaluation By: Auger Boring Pit � _ . ,___ - Cut .. ._. e.,...,_ . ._.. .. .. FACTORS ...:....1_ ...... _ 2 3 t+t" 4 g .,, :..,6.., , , . _ .� Landsca e position . ,�,� -• ,:;-j � Slope% 2 ` .. ' HORIZON I DEP'TH � p.- �' �� i o p - _ � _ (p • : T Texture rou /� � � � Consistence Structure .,:. � Mineralo . HORIZON II DEPTH ' � /(o /U - ( �- � 7— a- Texture rou G L G S �- L C. Consistence a � . Structure , h. • �,ti Mineralo ' �HORIZON III DEP"TH z- -- �-- .-- S'- - Texture rou GL L l�- L-- Consistence ' � Structure • Mineralo ' " HORIZON IV DEPTH . Texture rou Consistence Structure Mineralo ' SOIL WETNESS � t RESTRICTIVE HORIZON � - SAPROLITE CLASSIFICATION ' LONG-TERM ACCEPTANCE RATE �.� . �5 . �-- p� ,3 SITE CLASSIFICATION: � EVALUATION BY: �P�� � � LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: �� ���-�t� �'lI��� REMARKS: �4 "! �il LEGEND ' T,�ndscape Position R-Ridge S-Shoulder L-Lineaz slope FS-Foot slope N-Nose slope D, �' CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope Texture � , j G- S -Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Sih SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay - 3.5 ON�I4T .N . '" 7 11�15� VFR'-Very friable FR-Friable FI-Firm VFi-Very firm EFI-Extremely firm S�- � • NS-Non sticky SS-Slightly sticky S-Sticky VS =Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very.plastic Structure - �5 - � � SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angulaz blocky �� SBK-Subangular blocky PL-Platy PR-Prismatic �� � 1; Mine_r�alotv „` 1:1,2:1,Mixed lY.ot.eS ' . Horizon depth-In inches D� z Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface Saprolite-S(suitable),U(unsuitable) Soil wemess-Inches from land surface to free water or inches from land surface,to soil colors with chroma 2 or less 'Classification-S(snitable),PS(provisionally suitable),U(unsuitable) - - �` , - LTAR-LonQ-term accentance rate- eaUdav/ft2 ~'+ nrun ncinc�e..:;.ea. „ , , / i / ■t■������� ■��������1r��■����1������������■■1��■�■����ii�!\������1��8�.�0��■��■ 0■��rr��O■■�0���■■0��■��i�1■■�■■ ■■�������■��l��i�l���■5������0�■ ■�����������������u��������■■�■��i���e■������■■■������o����s�a�os■ ■�■����■���■o■�■���■�■■�■����������o���■������������■���■■��■;�oo�■ ■�■■�■�■�����■�■■�u�����■�����������■����■������■���■�■����s�►�o■o■ ■�����■����■■�����m�■■�■������v■���■■■���e���■�■������■■��■���t���■ ■�����������■�■■■�u��■���■��■���■�■■�■������������■���■���■���i��■■ ■�■���������������u��■■■��■���■����������■�■■����■����■■����■�����■ 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