622 Turrentine Church Rd (2) OPERATION PERMIT ice se n v
Davie County Health Department *CDP File Number 192100-1
A � 210 Hospital Street
P.O. Box 848 County ID Number.
'�==�•
Mocksville NC 27028 Evaluated For. REPAIR
Phone: 336-753-6780 Fax:336-753-1680 Township:
Applicant: Melissa Clary Property Owner: Melissa Clary
Address: 622 Turrentine Church Road Address: 622 Turrentine Church Road
r
City: Mocksville CRY: Mocksville
State/Zip: NC 27028 StatefZip: NC 27028
Phone#: (336)998-9504 Phone#: (336)998-9504
Pro a Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
622 Turrentine Church Road
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy,64 East right on,Dalton Rd to stop sign . tum left
#of Bedrooms: 4
#of People:
*Water Supply: NIA
*System Classification/Description:
*IP Issued by. TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by: 2140-Nations,Robert SaproliteSystem? ( Yes ONo
Design Flow: 4 8 0 GRAVITY-PARALLEL d-box Pump Required?
Distribution Type: (�' ) OYes ONo
Soil Application Rate: 0 a 7 5 *Pre Treatment:
Drain field
Ndrification Field 1 7 4 5 Sq. ft. *System Type: INFILTRATOROUICK4STAND
ARD
No. Drain Lines 5 Installer: Sherman Dunn
Total Trench Length: 4 3 6 ft• Certification#: 2702
Trench Spacing: _ 9 Inches O.C.
2Feet O.C. *EH S: 2140-Nations,Robert
Trench Width: _ 3 Olnehes
• Feet Date: 0 5 / 0 5 / 2 0 1 5
Aggregate Depth: inches
Minimum Trench Depth: 3 5
_ Inches
Minimum Soil Cover, a 4 Inches ,'Approval Status
Maximum Trench Depth: 3 6 Inches ® Approvetl O,Disapproved :-
Maximum Soil Cover: a 4 Inches
CDP Fite Number 192100 - 1 County ID Number:
Septic Tank
r��2
Lat.
STB:
Long:
1 . Installer.
Date: / Certification#:
THS:
*Filter Brand:
ST Marker, ❑ Yes ❑ No Date:
Reinforced Tank: C] Yes ❑ No Approval Status
1 Piece Tank: ❑ Yes ❑ Na
❑.Approved Dlsapproved� :
Pump Tank
rManufacturer. Installer:
PT: Certification#
Gallons: THS:
Date: / / Date: / / -
RiserSealed ❑ Yes ❑ No
RiserHeght: ❑ Yes ❑ No (Min.6 in.) ,*
Approval Status
Reinforced Tank: ❑ Yes ❑ No p Approved❑ Disapproved
1 Piece Tank: El Yes ❑ No
Supply Line
Pipe Size: inch diameter Installer:
Pipe Length: feet Certification#:
*Schedule:
THS:
Pressure Rated ❑ Yes ❑ No Date:
Approved fittings ❑ Yes ❑ NO Approva[Status
❑ Approved O3 Disapproved
s
Requirement
Pump Type: Installer.
Dosing Volume: - Gal Certification#:
Draw Down: Inches THS:
'Chain:
Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ N 0
Check-valve ❑ Yes ❑ N0 Approval Status
PVC unions [:1 Yes ❑ No ❑ Approve&&] Disapproved
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole ❑ Yes ❑ No
CDP flie Number 192100 - 1 County ID Number:
Electric Equipment
NEMA 4X 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:
Alarm Audible El Yes El No . Approvalstatus
0-Approved❑ Disapproved
Alarm Visible ❑ Yes ❑ No
2140• aeons.Robert
*Operation Permit completed by:
Authorized State Agent: Date of Issue: 0 5 / 0 5 / 2 0 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 TYPE ii 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: NIA
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency By Certified Operator:
N/A
Reporting Frequency By Certified Operator. N/A
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 hometbusiness 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 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:
921 fi0 - 1
210 Hospital Street
P.O.sox 848 County File Number:
Mocksville NC 27028 Date:
Olnch
Drawing Drawing Type: Operation Permit Scale: OQN A k ft.
1
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1-51
Fj-
I ... I
1
y" CONSTRUCTION For Office Use Only ,
AUTHORIZATION *CDP File Number 192100- 11Davie County Health Department County ID Number: '
210 Hospital Street Evaluated For: REPAIR
P.O. Box 848 Township:.
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone: 336-753-6780 Fax: 336-753-1680 0 3 / a 3 / a 0 a 0
Applicant: Melissa Clary Property Owner: Melissa Clary
Address: 622 Turrentine Church Road Address: 622 Turrentine Church Road
City: Mocksville City: Mocksville
State/Zip: NC 27028 State/Zip: NC 27028
Phone#: (336)998-9504 Phone#: (336)998-9504
Property Location & Site Information
rAddress/Road#: Subdivision: Phase: Lot:
ne Church Road
NC 27028 Directions
Structure: SINGLE FAMILY Hwy 64 East right on Dalton Rd to stop sign . turn left
#of Bedrooms: 4
#of People:
*Water Supply: NSA
System Specifications
Minimum Trench Depth:
raprolite
cation: Provisionally suitable a 4 Inches
Minimum Soil Cover:
stem? OYes 9No 1 a Inches
g 4 8 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 . a 7 5 Maximum Soil Cover: a 4 Inches
*System Classification/Description: *Distribution Type: GRAVITY-PARALLEL(eq.d-box)
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
Gallons
*Proposed System: 25%REDUCTION 1-Piece: OYes O No
Pump Required: O Yes O No O May Be Required
Nitrification Field 1 7 4 5 Sq.ft. Pump Tank: Gallons
No. Drain Lines 4 1-Piece: OYes ONo
Total Trench Length: 4 3 6 ft. GPM--vs— ft. TDH
Trench Spacing: Inches O.C.
— g Feet O.C. Dosing Volume: _ Gallons
Trench Width: _ 3 OInches
®Feet Grease Trap: Gallons
Aggregate Depth: inches Pre-Treatment: O NSF OTS-1 O TS-II
Septic Tank Installer Grade Level Required: O 1 O II O III O N
Page 1 of 3
' CDP File Number 192100 - 1 County ID Number: AK w
❑ Open Pump System Sheet
Repair System Required:0 Yes O No O No, but has Available Space
Repair System
Trench Spacing: O Inches O. .
*Site Classification: — O Feet O.C.
Trench Width: O Inches
Design Flow: _ Q Feet
Soil Application Rate: Aggregate Depth: inches
. Minimum Trench Depth:
*System Classification/Description: Inches
Minimum Soil Cover:
Inches
Maximum Trench Depth:
*Proposed System: Inches
Maximum Soil Cover:
Nitrification Field Sq.ft. Inches
No. Drain Lines *Distribution Type:
Total Trench Length: ft Pump Required: OYes O No O 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 meinr g
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. CRemaining
haracters
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(A 937(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 O No
Applicant/Legal Reps. Signature- Date:
*Issued By: 2140-Nations,Robert of Date of Issue: 0 3 a S / a 0 1 5
Authorized State Agent: Malfunction Log OYeS ;'
®Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
N . J
10 CONSTRUCTION AUTHORIZATION 192100 - 1
Davie County Health Department CDP File Number:
210 Hospital Street '
County File Number:
P.O.Box 848
Mocksville INC 27028 Date: 03 / a5 / a015
O Inch
Drawing Drawing Type: Construction Authorizatio Scale: , 00 Block ft.
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Page 3 of 3
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CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street CDP File Number: 192100 - 1
P.O.Box 848
Mocksville NC 27028 County File Number:
Date: A:3 / a 5 / a 0 15
Click below to import an image from an external location: Drawing Type:Construction Authorization
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