177 Oakcrest Dr Lot 56OPERATION PERMIT
Davie County Health Department
° ¢ 210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: True Homes/Jackie Self
Address: 2649 Brekonridge Centre Dr
City: Monroe
State/Zip: NC 28110
Phone #: (336) 992-2477
*CDP File Number 218851 - 11
County ID Number:
Evaluated For: NEW
�ownship:
//Property Owner: Taylor Williams
Address: 2990 Bethesda Place Suite
City: Winston-Salem
State/Zip: 27103
Phone #:
Property Location & Site Information
Address/Road #: Subdivision: Summer Hill Farms Phase: Lot: 56
177 Oakcrest Drive
Advance NC 27006
Structure: SINGLE FAMILY
# of Bedrooms: 4
# of People: 8
*Water Supply: N/A
*IP Issued by: 2140 - Nations, Robert
*CA Issued by: 2140 - Nations, Robert
Design Flow: 4 8 0
Soil Application Rate: 0 a 5
Nitrification Field
No. Drain Lines
Total Trench Length
Trench Spacing:
Trench Width:
Aggregate Depth:
Hwy 801 South off of 1-40, right on Markland Rd
*System Classification/Description:
TYPE III G. OTHER NON-CONV. TRENCH SYSTEMS
Saprolite System? J Yes X, No
*Distribution Type: PUMP TO GRAVITY Pump Required?
X Yes 0 No,
*Pre -Treatment:
Drain field
1 9 a 0 Sq. ft.
6
4 8 4 ft.
9 0Inches O.C.
(9 Feet O.C.
3 Olnches
(9 Feet
inches
Minimum Trench Depth:
3
6
Inches
Minimum Soil Cover:
a
4
Inches
Maximum Trench Depth:
3
6
Inches
Maximum Soil Cover:
)
4
Inches
Page 1 of 4
*System Type: INFILTRATOR QUICK STANDARD
Installer: Ronnie Overbey
Certification #: 1143
*EHS: 2140 - Nations, Robert
Date: 1 1 / 1 6/.1 0 1 7
Approval Status
X❑ Approved ❑ Disapproved
CDP File Number 218851 - 11
Manufacturer: WMs
STB: 364
Gallons: 1000
Date:
1
0/
1 3/
a 0 1 7
*Filter Brand:
POLYLOK
PL
-122 With Pipe Adapter
ST Marker:
❑
Yes
❑X
No
Reinforced Tank:
ElYes
Yes
❑X
No
\
\Piece Tank:
❑
Yes
❑X
No
Manufacturer: WMs
County ID Number:
septic i anK
Lat.
PT:
92
Installer:
Gallons:
1250
Date:
1
0/
1 3/
x 0 1 7
Riser Sealed
❑X
Yes
❑
No
Riser Height:
❑X
Yes
❑
No (Min. 6 in.)
Reinforced Tank:
❑X
Yes
❑
No
\ 1 Piece Tank:
❑X
Yes
❑
NO
/ Pipe Size: a inch diameter
Pipe Length: 1 0 6 feet
*Schedule: 40
Pressure Rated X❑ Yes
Approved fittings X❑ Yes
Long:
In
Installer: Ronnie Overbey
Certification #: 1143
*EHS: 2140 - Nations, Robert
Date: 1 1 / 1 6/ x 0 1 7
Approval Status
X❑ Approved ❑ Disapproved
Pump Tank
Installer: Ronnie Overbey
Certification #: 1143
*EHS: 2140 - Nations, Robert
Date: 1 1 / 1 6/ a 0 1 7
Approval Status
❑X Approved ❑ Disapproved
Supply Line
Installer: Ronnie Overbey
Certification #: 1143
*EHS: 2140 - Nations, Robert
❑ No Date: 1 1/ 1 6/ a 0 1 7
❑ No Approval Status
0 Approved ❑ Disapproved
Pump Type: Zoeler
Installer:
Ronnie Overbey
Dosing Volume:
-
Gal Certification #:
1143
Draw Down:
Inches
*EHS:
2140 - Nations, Robert
*Chain: ROPE
1 1 / 1 6 / a 0 1 7
Date:
Valves Accessible
0
Yes
❑
No
Flow Adjustment Valve
0
Yes
❑
No
Check -valve
0
Yes
❑
No
Approval Status
PVC unions
0
Yes
❑
No
0
Approved ❑ Disapproved
Vent Hole
0
Yes
❑
NO
Anti -siphon Hole
0
Yes
❑
No
Page 2 of 4
CDP File Number 218851 - 11
County ID Number:
NEMA 4X Box or Equivalent
❑X
Yes
❑
NO
Installer:
Ronnie Overbey
Box 12 inches Above Grade
❑X
Yes
❑
NO
1143
Certification #:
Box Adj. To Pump Tank
❑X
Yes
❑
No
Conduit Sealed
❑X
Yes
❑
NO
*EHS:
2140 - Nations, Robert
Pump Manually Operable
❑X
Yes
❑
No
*Activation
Date:
1 1/ 1 6 x 0 1 7
Method:
CONTROL
Alarm Audible ® Yes
Alarm Visible ❑X Yes
*Operation Permit completed by_
Approval Status
El No
El No XApproved ❑ Disapproved
2140 - Nations, Robert
Authorized State Agent: Date of Issue: 1 1/ 1 9/.1 0 1 7
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 iii G. sewage septic system.
Rule .1961 requires that a Type TYPE iii G. septic system meet the following criteria:
Minimum System Review By The 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 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.
9 Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 3of4
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Operation Permit
1 -1
CDP File Number: 218851 -
County File Number:
Date: / /
O Inch
Scale: O Block
O N/A
s
ZS -1
Page 4 of 4 P1 P2 P3
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC
CDP File Number:
27028 County File Number:
Date:. . /
Click below to import an image from an external location: Drawing Type: Operation Permit
Page 4 of 4 P1 P2 P3
Drain Field: System Final Inspection Log:
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Septic Tank:
Pump Tank:
Supply Line:
Pump Requirements:
Electrical Equipment:
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