130 Twelve Oaks TrailOPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Kraig and Amy Nutall
Address: 30599 Canterbury Park Drive
City= Winston-Salem
State/Zip: NC 27127
Phone u:
ro
Address/Road #: 0130
Twelve Oaks Trail
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 4
# of People:
*Water Supply: NIA
*IP Issued by: 2140 - Nations, Robert
*CA issued by: 2140 - Nations, Robert
Design Flow: 3 6 0
Soil Application Rate: 0 a
Nitrification Field
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Aggregate Depth:
*CDP File Number 196536-2
5758677237
County ID Number.-
Evaluated
umber:Evaluated For: NEW
Township:
perty Owner: Kraig and Amy Nutall
Address: 30599 Canterbury Park Drive
Cay, Winston-Salem
State/Zip: NC 27127
Phone #:
ierty Location & Site Information
Subdivision: Phase: Lot:
Directions
Hwy 64 East left on Cornatzer R. To Twelve Oaks
Trail property is north of Twelve Oaks
*System Classification/Description:
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
Saprolite System? QYes (J)No
*Distribution Type: GRAVITY - PARALLEL (eq. d -box) Pump Required?
QYes ®No
'Pre -Treatment:
Drain field
1 8 0 0 Sq. ft.
3
4 5 0 ft.
9w Inches O.C.
Feet O.G.
3 Inches
Feet
inches
Minimum Trench Depth: 3 6
Inches
Minimum Soil Cover a 4
Inches
Maximum Trench Depth: 3 6
Inches
Maximum Soil Cover: a 4
� Inches
*System Type: INFILTRATOR QUICK 4 STANDARD
Installer: Mike Clodielter
Certification #: 2695
*EH S: 2140 - Nations. Robert
Date: 0 4/ 0 4/ x 0 1 6
Approval Status
Fil Approved [71 Disapproved
CDP File Number 196536-2
Manufacturer. Shoaf
County ID Number: 5758677237 r
QVPLI : 1011K
Lat.
STB :
766
❑
No
Gallons;
1000
Yes
❑
Date:
0 a/
0 3/
a 0 1 6
'Filter Brand:
POLYLOK PL -122 With Pipe Adapter
ST Marker:
❑ Yes
E
No
Reinforced Tank:
❑ Yes
F#1
No
\ 1 Piece Tank:
❑ Yes
®
No
Manufacturer.
PT:
Yes
❑
No
Gallons:
PVC unions ❑
Yes
❑
Date:
❑ Approved ❑ Disapproved
Vent Hole ❑
Yes
Riser Sealed ❑
Yes
❑
No
Riser Height: ❑
Yes
❑
No (Min.6 in.)
Reinforced Tank: ❑
Yes
❑
No
1 Piece Tank: ❑
Yes
❑
No
/ Pipe Size: inch diameter
Pipe Length: feet
*Schedule:
Pressure Rated ❑ Yes ❑ No
Approved fittings ❑ Yes ❑ No
N
Long:
Installer: Mike Ciodfelter
Certification #: 2695
*FHS; 2140 - Nations. Robert
Date: 0 4/ 0 4/ 0 0 1 6
Approval Status
Approved ❑ Disapproved
Pump Tank
Installer:
Certification #:
*EH S:
Date:
Approval Status
❑ Approved ❑ Disapproved
unniv Line
Installer:
Certification #:
'EHS:
Date / /
Approval Status
❑ Approved ❑ Disapproved
f Pump Type: Installer:
% Dosing Volume: — Gal Certification #:
Draw Down: Inches 'EHS:
'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
\L Anti -siphon Hole ❑
Yes
0
No
CDP File Number 196536-2
County ID Number: 5758677237
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
'ENS:
Pump Manually Operable
❑
Yes
❑
No
'Activation Method:
Date:
Alarm Audible ❑ Yes
Alarm Visible ❑ Yes
'Operation Permit completed by
❑ No Approval Status
El No D Approved D Disapproved
2140 - Nations, Robert
Authorized State Ager-�- L'---- Date of Issue: 0 4 / 0 4 / 2 0 1 6
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 It A. sewage septic system.
Rule .1961 requires that a Type TYPE n 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: N/A
Rule .1961 requires that a Type IV and V septic systems designed fora homelbusiness 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 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 ownerand 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.**
Drawinp,
C-
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Type: Operation Permit
CDP File Number: 196636 - 21
County File Number. 5758677237
Date: / /
Olnch
Scale: OBlock
ONIA
G
EAN
d
f
CONSTRUCTION
AUTHORIZATION
Davie County Health Department
. 210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Kraig and Amy Nutall
Address: 30599 Canterbury Park Drive
City: Winston-Salem
State/Z ip: NC 27127
Phone #:
For Office Use On[
"CDP File Number 196536-2
County ID Number: 5758677237
Evaluated For: NEW
�, Township:
T VALID UNTIL:
1 0/ 1 5/ a 0 a 0
Property Owner: Kraig and Amy Nutall
Address: 30599 Canterbury Park Drive
City: Winston-Salem
State/Zip: NC 27127
Phone #:
Property Location & Site Information
/'Address/Road #: Subdivision:
Twelve Oaks Trail
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 4
# of People:
"Water Supply: N/A
Phase: Lot:
Hwy 64 East left on Cornatzer R. To Twelve Oaks Trail
property is north of Twelve Oaks
Septic Tk
*Proposed System: 25% REDUCTION
Nitrification Field
1 8 0 0 sq. ft.an.
1 0 0 0 Gallons
1 -Piece: OYes ®No
Pump Required: OYes *No OMay Be Required
Pump Tank: Gallons
No. Drain Lines 5 1 -Piece: QYes ONo
Total Trench Length: 4 5 0 fit. GPM—vs-- ft. TDH
Trench Spacing:— 9 �Feet
Inches O.C. Dosing Volume: Gallons
O.C.
Trench Width: 3 Inches
Feet Grease Trap: Gallons
Aggregate Depth: - -
inches Pre -Treatment: O N SF OTS -1 OTS -II
Septic Tank Installer Grade Level Required: 01 OII 0111 OIV
Do I of Z
Minimum Trench Depth:
a
4
\
Site Classification:
Provisionally Suitable
Inches
Minimum Soil Cover.
1
a
Saprolite System?
()Yes ®No
Inches
Design Flow:
3 6 0
Maximum Trench Depth:
3
S
Inches
Soil Application Rate:
0 a
Maximum Soil Cover:
a
4
Inches
'System Classification/Description:
"Distribution Type:
GRAVITY - PARALLEL (eq. d -box)
TYPE Il A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
Septic Tk
*Proposed System: 25% REDUCTION
Nitrification Field
1 8 0 0 sq. ft.an.
1 0 0 0 Gallons
1 -Piece: OYes ®No
Pump Required: OYes *No OMay Be Required
Pump Tank: Gallons
No. Drain Lines 5 1 -Piece: QYes ONo
Total Trench Length: 4 5 0 fit. GPM—vs-- ft. TDH
Trench Spacing:— 9 �Feet
Inches O.C. Dosing Volume: Gallons
O.C.
Trench Width: 3 Inches
Feet Grease Trap: Gallons
Aggregate Depth: - -
inches Pre -Treatment: O N SF OTS -1 OTS -II
Septic Tank Installer Grade Level Required: 01 OII 0111 OIV
Do I of Z
CDP File Number 196536-2 County ID Number: 5758677237 f,
❑ Open Pump System Sheet
Repairbystem Requireo:vTes utvV vivo, IJut.IIdbrwdndute Opdce
/Repair System
Trench Spacing:
1
9 Q Inches 0.
*Site Classification:
Provisionally Suitable
— ao Feet O.C.
Design Flow:
Trench Width:
Q Inches
3 Feet
3 6 0
_ •
Aggregate Depth:
Soil Application Rate:
0
inches
u
Minimum Trench Depth:
a 4
*System Classification/Description:
Inches
TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS; Minimum Soil Cover:
1
Inches
Maximum Trench Depth:
3 6
*Proposed System:
25% REDUCTION
Inches
Maximum Soil Cover:
a 4
Nitrification Field
1 8 0
Inches
Sq. ft.
No. Drain Lines
*Distribution Type:
GRAVITY - PARALLEL (eq. d -box)
5
Total Trench Length:
4 5 0Pump
Required: OYes
®No
OMay Be Required
ft.
\
Pre -Treatment. ONSF
OTS
-1 OTS -II ,
*Site Modifications
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. ;
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 maybe suspended or revoked (.1937(8)). 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/ 1 9/ x 0 1 5
Authorized State Ate' Malfunction Log Oyes
®Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.Q. Box 848
Mocksville NC 27028
Di-a-witng Drawing Type: Construction Authorization
�K�r p4��
CDP File Number: 196536 - 2
5758677237
County File Number:
Date: 1 0 / 1 9 / x 0 1 5
}Inch
Scale: , , 013lock = _
(jN!A
I
C
[i#
15(-Q') -
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
CDP File Number: 196536 - 2
County File Number: 5758677237
Date:.1 0/ 19 / a 0 1 5
Click below to import an image from an external location: Drawing Type: Construction Authorization
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APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT &ATC
Davie County Environmental Health
P.O. Box 848/210 Hospital Street
TDI Mocksville, NC 27028
(336)753-6780/ Fax (336)753-1680
Applica Site Evaluation/Improvement Permit XAuthorization To Construct (ATC) ❑ Both
Type of Application: XNew System ❑Repair to Existing System ❑Expansion/Modification 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.
APPLICANT INFORMATION
Name Vww%a IyLAOM Contact Person Ihrcia t-UPCOAI
Address ��yg9 Waker�heQ1 (' ir-cle Home Phone 3-310-3t-i-S311e9
City/State/ZIPNC Business Phone
Email V%ro.� q \ Email:
Name on Perm ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMA ON *Date House/Facility Corners 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 expiration with complete plat.)
Owner's Name \i xmr a LLkNal\ Phone Number33(o-35y-%169
Owner's Address City/State/Zip
Property Address City
Lot Size to AHLI AcreS Tax PIN# Tax Lo : 3lo.OS —Tax 9"T
Subdivision Name(if applicable) Section/Lot# 31D.05
Directions To Site: (DL-{ 'f --a4 Le -4 on Cornzed Lei- on Toe1ve. OaKS
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 XNo
Does the site contain jurisdictional wetlands? _Yes X_No
Are there any easements or right-of-ways on the site? _Yes XNo
Is the site subject to approval by another public agency? _Yes VNo
Will wastewater other than domestic sewage be generated? Yes RNo
IF RESIDENCE FILL OUT THE BOX BELOW
# People L4_ # Bedrooms Bathrooms Garden Tub/Whirlpool ❑Yes Flo
Basement: ❑Yes )440 Basement Plumbing: ❑Yes Flo
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:XConventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: ❑ County/City Water ❑ New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes
If yes, what type?
X No
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 charges, 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 Hea a ent to conduct necessary inspections to determine compliance with applicable laws and rules
I underst that I am a or the proper identification and labeling of property lines and corners and locating and flagging
or -,house a 1 ation, proposed well location and the location of any other amenities.
i
Pr 7717
peL;;
'wner's legal representative signature Site Revisit Charge
Date(s):
Client Notification Date:
Dat EHS:
Sign given ❑Yes ❑No Account #
Revised 11/06 Invoice #
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