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486 Howardtown Rd (2)OPERATION PERMIT Davie County Health Department ° ¢ 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Sherrie Smith Address: 486 Howardtown Rd City: Mocksville State/Zip: NC 27028 Phone #: (336) 251-5262 Property Loca Address/Road #: Subdivision: 486 Howardtown Road Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: *Water Supply: EXISTING WELL *IP Issued by: *CA Issued by: 2140 - Nations, Robert Design Flow: 4 8 0 Soil Application Rate: 0 1 5 Nitrification Field No. Drain Lines Total Trench Length Trench Spacing: Trench Width: Aggregate Depth: *CDP File Number 244699 - 1 5860109817 County ID Number: Evaluated For: EXPANSION �ownship: /Property Owner: Sherrie Smith Address: 486 Howardtown Rd City: Mocksville State/Zip: NC 27028 Phone #: (336) 251-5262 ion & Site Information Phase: Lot: Hwy 158 east, right on Howardtown Rd. *System Classification/Description: TYPE III G. OTHER NON-CONV. TRENCH SYSTEMS Saprolite System? '.,Yes X, No *Distribution Type: GRAVITY -SERIAL Pump Required? 0 Yes X No, *Pre -Treatment: Drain field 8 0 0 Sq. ft. 3 a00ft. 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: Rusty Miller Certification #: 1129 *EHS: 2140 - Nations, Robert Date: 1 1/ a 1/ a 0 1 7 Approval Status X❑ Approved ❑ Disapproved CDP File Number 244699 - 1 County ID Number: 5860109817 Manufacturer: Pump Type: PT: se tic i anK inch diameter Manufacturer: Riser Sealed ❑ Yes Lat. ❑ Yes Reinforced Tank: ❑ Yes \ 1 Piece Tank: ❑ Yes Long: ❑ No STB: Approved fittings ❑ Yes ❑ No *EHS: Approval Status Gallons: *Chain: ❑ Approved ❑ Disapproved Installer: Date: Certification #: Date: *EHS: Valves Accessible *Filter Brand: Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No ST Marker: ❑ Yes ❑ NO Date: ❑ Reinforced Tank: ❑ Yes ❑ NO PVC unions Approval Status Yes ❑ No ❑ El Approved El Disapproved 1 Piece Tank: El Yes El NO NO Manufacturer: Pump Type: PT: Gallons: inch diameter Date: Riser Sealed ❑ Yes Riser Height: ❑ Yes Reinforced Tank: ❑ Yes \ 1 Piece Tank: ❑ Yes ❑ No ❑ NO (Min. 6 in.) ❑ No ❑ No Pump Tank Installer: Certification #: *EHS: Date: Approval Status ❑ Approved ❑ Disapproved / Pump Type: Supply Line Pipe Size: inch diameter Installer: Pipe Length: feet Certification #: *Schedule: *EHS: Pressure Rated ❑ Yes ❑ No Date: Approved fittings ❑ Yes ❑ No *EHS: Approval Status *Chain: ❑ Approved ❑ Disapproved / 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 Anti -siphon Hole ❑ Yes ❑ No Page 2 of 4 CDP File Number 244699 - 1 County ID Number: 5860109817 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: Approval Status Alarm Audible El Yes ElNo ❑Approved ❑ Disapproved Alarm Visible El Yes ElNO 2140 - Nations, Robert *Operation Permit completed by_ Authorized State Agent: Date of Issue: 1 1 / a 0 / a 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 U CDP File Number: 244699 - 1 County File Number: 5860109817 Date: / / 0Inch Scale: 0 Block 0 Nip n cx �, Page 4of4 P1 P2 P3 .4- 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 5860109817 Page 4 of 4 P1 P2 P3 Drain Field: System Final Inspection Log: Characters Remaining 4000 Septic Tank: Pump Tank: Supply Line: Pump Requirements: Electrical Equipment: P1 P2 P3 Characters Remaining 4000 Characters Remaining 4000 Characters Remaining 4000 Characters Remaining 4000 Characters Remaining 4000