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217 Vanzant Rd (2) OPERATION PERMIT or, ice se nv s: Davie County Health Department *CDP File Number 123017-1 210 Hospital Street H2.000-00-044 P.O.Box 848 County I©Number. Mocksville NC 27028 Evaluated For: NEW Phone:336-753-6780 Fax:336-753-1680 Township: Applicant: Ronnie Jones Property owner: Nickolas Gibieti0 Address: 142 Cedar Hill Lane Address: 18321 Dembridge Drive City: Advance City: Davidson State)Zip: NC 27006 State/Zip: NC 28036 Phone#: (336)909-1193Phone#: (704)402-4188 Property Location & Site information Address/Road#: Subdivision: Phase: Lot: 217 Vanzant Road Mocksville NC 27028 Directions structure: SINGLE FAMILY Hwy,64 West from Mocksville Left on Vanzant Rd. Just before Lake Myers. Property 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 ONo Design Flow: 3 6 0 Pump Required? *Distribution Type: GRAVITY-SERIAL (�Yes QNo Soil Application Rate: 0 - 3 *Pre Treatment: Drain field r ication Field 1 2 0 0 Sp•ft• *System Type: INFILTRATOROUICK4STANDARD rain Lines 4 Installer: Sherman Dunn Total Trench Length: 3 0 0 ft. Certification#: 2702 Trench Spacing: 9 ()Incheslnches O.C. — (r)Feet O.C. EHS: 2140-Nations.Robert Trench Width: 3Inches gffeet Date: 0 6 / 0 4 / .1 0 1 4 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover, a q inches AppcovalStatus Maximum Trench Depth: 3 6 ® Approvetl O DisapproVetl Inches Maximum Soil Cover: 2 4 Inches CDP File Number 123017- 1 Septic Tank County ID Number: H2-0oa00.044 Manufacturer. Shoaf Let. : STB: . 760 Long - Gallons: 1000 Installer Sherman Dunn Date: 0 11 2 4 / a 6 1 4 Certification#: 2702 *EHS: 2140.Nations,Robert *Filter Brand: POt riOK PL-122 With Pipe Adapter ST Marker. El Yes ® No Date: � 6 / � 4 / a � 1 � Reinforced Tank: ❑ YeS ® No Approval Status 1 Piece Tank: ❑ Yes ® No TWO Pump Q .Disappiz roved Pump Tank Manufacturer Installer PT: Certification#: Gallons: *EHS: Date: / / Date. RiserSeeled ❑ Yes ❑ No RiserMeght: [IYes . 13 No (Min.6 in.) SPP al Status einforced Tank: ❑ Yes ❑ No _ O Approved❑ Disapproved 1 Piece Tank: ❑_Yes _ 13 No �... Supply Line Pipe Size: inch diameter Installer Pipe Length: feet Certification 9: *Schedule: *EHS: Pressure Rated ❑ Yes ❑ No Date: Approved fittings ❑ Yes ❑ NoAPPcovatStatus ❑ Approved❑ :Disapproved Pump eu Pump Type: installer. Dosing Volume: - Gal Certification#: Draw Down: Inches *EHS: *Chain: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check-valve C3 Yes ElNo Approvalstatus PVC unions ❑ Yes El No ❑ ApDroved❑ Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ Yes ❑ No CDP File Number 123017- 1 County ID Number: H2-000.00.044 Electric Equipment NEMA4XBox orEquivalent E3 Yes ❑ No Installer. Box 12 inches Above Grade ❑ Yes E3 No Certification#: Box Adj.To Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No *EHS: Pump Manually Operable ❑ Yes ❑ NO *Activation Method: Date: Approval Status Alarm Audible ❑ Yes ❑ No Approved❑ Disapproved alarm visible ❑ ��es ❑�WoMU 2140-Nations,Robert *Operation Permit completed by: Authorized State Agent —'-- Date of Issue: 0 6 / 0 4 / 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 Il 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: N/A Management Entity: OWNER Minimum System Inspection/Maintenance Frequency ByCedified Operator. NIA 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. O Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT 123017 - 1 Davie County Health Department CDP File Number: 210 Hospital Street H2-000.00.044 P.O.Box WCounty File Number: Mocksville NC 27028 Date: ! / Olnch Drawing Drawing Type: Operation Permit OScale: ON lock ft. I i II 1 _ . io el -- ,, Ay- I l I F I CONSTRUCTION For office use only AUTHORIZATION �f�I��is *CDP File Number 123017-';'-1 Davie County Health Department „/n County ID Number: 1-12-000-00.044 f 210 Hospital Street (,�f✓/ry Evaluated For: NEW P.O. Box 848 •�«..•• Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone:336-753-6780 Fax:336-753-1680 1 1 3 / 2 0 1 8 Applicant: Ronnie Jones Property Owner. ickolas Gibieti$ Address: 142 Cedar Hill Lane Address: 18321 Dembridge Drive City: Advance City: Davidson StatefZip: NC 27006 State/Zip: NC 28036 Phone#: (336)909-1193 Phone# �402-441�88 : (704) Property Location & Site Information Address/Road#: ,J7 Subdivision: Phase: Lot: Vanzant Road Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 64 West from Mocksville Left on Vanzant Rd. Just #of bedrooms: 3 before Lake Myers. Property on left #of People: 3 *Water Supply: NEW WELL System Specifications Minimum Trench Depth: Site Classification: PS 2 4 Inches Minimum Soil Cover. Saprolite System? OYes ONo Inches Design Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 • 3 Maximum Soil Cover: Inches *System Classification/Description: *Distribution Type: TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPO OR LESS) Septic Tank: _ 1 0 0 0 _ Gallons *Proposed System: 25%REDUCTION 1-Piece: OYes QNo Pump Required: OYes (E)No OMay Be Required Nitrification Field Sq.ft. Pump Tank: Gallons No. Drain Lines 1-Piece:OYes ONo Total Trench Length: 3 0 0 ft GPM—vs— ft. TDH Trench Spacing: Inches O.C. 8Feet O.C. Dosing Volume: Gallons Trench Width: Inches — Feet Grease Trap: Gallons Aggregate Depth: inches _ Pre Treatment: ONSF OTS-1 OTS-II Septic Tank Installer Grade Level Required: 01011 OIII OIV Pagel of 3 CDP File Number 123017 - 1 County ID Number. H2-000-00-044 ❑ Open Pump System Sheet Repair System Required:OYes ONo ONO, but has Available Space rDesign System Trench Spacing: Inches O. . ification: PS — Feet O.C. Trench Width: Inches w: 3 6 0 — 8Feet SoilAggregate Depth: Application Rate: 0 - 3 inches ._ Minimum Trench Depth: 2 4 Inches *System Classification/Description: TYPE 11 A CONY SYSTEM(SINGLE-FAMILY OR 480 GPO OR LESS) Minimum Soil Cover. Inches 'Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: Nitrification Field Sq.ft Inches No. Drain Lines `Distribution Type: GRAvmr-SERIAL Total Trench Length: 3 0 0 ft Pump Required: OYes QNo OMay Be Required Pre Treatment: ONSF 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. *Permit Conditions The issuance of this permit bythe 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 may be suspended or revoked(.1937(8)).The person owning or controlling the system shall be responsible forassuring compliance with the laws,rules,and permit conditions regarding system location,installation,operation,mainteramce;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: 1 1 / 1 3 / 2 0 1 3 Authorized State Agent: (IlkMalfunction Log Oyes @Hand Drawing Olmport Drawing Total Time:(H H.-M M) **Site Plan/Drawing attached.** Page 2 of 3 0 1 Hours 0 0 tt inutes S-8-CKS issued-new CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number: 123017 - 1 210 Hospital Street 1-12-000-00-044 P.O.Box 848 County File Number: Mocksville NC 27028 Date: 1 1 / 1 3 / 2 0 1 3 Olnch Dra`ving Drawing Type: Construction Authorisation Scale: OBlock = ft- ON/A L—L 16 ir jz:w , I 1 tt _ 11 i I `• � i � � � I � I i i � i i � i � - - -� --7 -- --� --�-- Pane 3 of 3 _ Y A For Office Use Only IMPROVEMENT PERMIT *COPFileNumber 123017-1 Davie County Health Department H2-000.00.044 �t 210 Hospital Street County ID Number: P.O. Box 848 Evaluated For. NEW Mocksville NC 27028 Township: Phone: 336-753-6780 Fax:336-753-1680 PERMIT VALID UNTIL: 9/12/2018 "NOTE TO INSPECTIONS DIVISION: Building Permits cannot be Issued with this Improvement Permit. r pplicant: Ronnie Jones Property Owner: Nickolas Gibieti0 ddress: 142 Cedar Hill Lane Address: 18321 Dembridge Drive ity: Advance city: Davidson State/Zip: NC 27006 State/Zip: NC 28036 Phone#: (336) 909-1193 Phone#: (704)4024188 Property Location & Site Information Address/Road #: Subdivision: Phase: Lot: Vanzant Road Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 64 West from Mocksville Left on Vanzant Rd. #of Bedrooms: 3 Just before Lake Myers. Property on left #of People: 3 ' 'Water Supply: NEW WELL System Specifications nitial System 'Site assI x:a an: PS Minimum Trench Depth: 2-`:4 Inches Saprolite System? OYes @No Maximum Trench Depth: 3 6'+ a Inches Design Flow: 3 6 0 Septic Tank: ��"% 1 0 0 • Gallons Soil Application Rate: 0 . 3 1-Piece: OYes ONo Pump Required: OYes @No OMay Be Required 'System Class ificatan/Description: TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons LESS) "Proposed System: 25%REDUCTION 1-Piece: OYes ONo Repair System Required:@Yes ONo ONO, but has Available Space Repair System 'Site Classification: PS Minimum Trench Depth: 2 4 Inches Soil Application Rate: 0 3 Maximum Trench Depth: 3 6 Inches 'System Classification/Description: Pump Required: OYes Q No O Maybe Required TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) "Proposed System: 25%REDUCTION Pagel of 3 i CDP File Number 123017 - 1 County ID Number: 1-12-000-00.044 "Site Modifications ❑ 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 ofthis permit bythe Health Department in no wayguarantees 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 5years from date of Issue with a site plan(means a drawing not necessarily drawn to O sale that shows the existing and proposed property lines with dimensions,the location of thefacility and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters). Plat The Improvement Permit shag be valid without expiration with plat(means a property surveyed prepared by a registered land surveyor,drawn to a sale of one inch equals no more than 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 and5urface 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 satisty the conditions,the rules,or this article.This pennit Is subject to revocation if the site plan,plat,or intended use changes(NCGS 130A335(n).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 ApplicanULegal Reps. Signature: Date: *Issued By: 2244-Daywalt,Andrew Date of Issue: 0 9 1 2 2 0 1 3 Authorized State Agent: OAA � OValid without Expiration? O Create CA? OHand Drawing Olmport Drawing **Site Plan/Drawing attached.** Total Time:(H1-111 .,) 0 1 Hours 0 0 minutes Page 2 of 3 • J • IMPROVEMENT PERMIT Davie County Health Department CDP File Number: 123017 - 1 210 Hospital Street H2.000-00.044 P.O.Box 848 County File Number: Mocksville NC 27028 Date: Q Inch Drawing Drawing Type: Improvement Permit Scale: , QBlock QN/A G 1 i s � i , s Ur V { r APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health 's Cr ,Iv P P.O.Boz 848/210 Hospital Street D E Dom: 2 3 3 # Mocksville,NC 27028 w` b Received b : (336)753-6780/Fax 36)753-1680 �3 �3 Application For: iNew aluation/Improvement Permit Authonzahon 10 To onstruc ATC) ❑ Both Type of Application: 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. APPMANT TWORMATION _. Name Contact PersonDom. '�O AddressHome Phone 'City/State/ZIP 17 1(2 -2 20Business Phone / Email r�� Name on Permit/ATC ifD�erent than Above _ l"�LLs=/D Mailing Address City/Statef2ip 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 expiration with complete plat.) Owner's Name-75ZO Pho e N ber you - �$ Owner's Address /0 ...City/State/Zip Property Address City .C. o7�C�aQ Lot.Size f3, aim Tax PIN#� / 9b i QI q� )42 -000. 001-04V Subdivision Name(if applicable) Section/Lot# Directions To it cam. A& i , If the a4swer to Ay of the foillowing qu stions is"Y s", pporting d cumeatation must-be attache Are there any existing wastewater systems on the site? Yes Vk Does the site contain jurisdictional wetlands? Yes Are there any easements or right-of-ways on the site? Yes o Is the Sike_subject to approval by another public agency? Yes1 Will wastewater other than domestic sewage be generated? Yes o TF RF,SIDENC E FTT T,01 TT THF BOX BELOW #People 13 #Bedrooms # p Bathrooms .3 Garden Tub/Whirl ool ❑Yes Vflo Basement: Mies ❑No Basement Plumbing: Yp es ❑No vZ IF-NON-R1 SIDF,NC E FITS,OUT THE BQX.BFJ,0W 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: 05onventional ❑Accepted ❑Innovative ❑Altemative ❑Other Water Supply Type: ❑ County/City Water WXlew Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?T1 Yes "o 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 faWfied or changed I hereby grant right of entryto 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 corners and locating and flagging ors g the h /facility loca on,proposed well location and the location of any other amenities. Pro owner's or owner's le representative signature Site Revisit Charge b Date(s): Q e3 —13 Client Notification Date: Date EHS: n 3x17 ��57 Sign given ❑Yes ❑No Account# Revised 11/06 Invoice# ���� I l Z �ECEI'VED i Dow M Jt Z/ *76 b o � r � T' ry �i:' sJ �' ,i `r s� ',r (l l 'r J 1.:,'{h" ✓/ :�' VK ,s' �•� ��AYv r r ,T h { &rr .r'Ys l K� 1 ii .. rit � �� • ` a ,r."h 4{ ,�`1�'lv� ,Frrrirr ��J�rt- .�'�ys 3 r • avp._ A, gr 1 !t`' 1 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil,/Site Evaluation APPLICANT INFORMATION ,PIC1)"ERTY INFORMATION Account #: 989900079 Tax PIN/EH#: H2- - - Billed To: Ronald Jones Subdivision Info: Reference Name: Location/Address: Vanzant Road-27028 Proposed Facility: Residence Property Size: 13.54 Ac Date Evaluated: of Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope% HORIZON I DEPTH �.- Texture group Consistence Structure Mineralogy HORIZON R DEPTH Texture group Consistence Structure Mineralogy ; HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLTTE CLASSIFICATION D LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: S EVALUATION BY., LONG-TERM ACCEPTANCE RATE: � _ OTHER(S)PRESENT: �� �/ �T,lJwt REMARKS: LEGEND j, n s ape 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 Texture 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 A�ist 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 l tes 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 or less. 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