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147 Sawgrass Drive Lot 291OPERATION PERMIT Davie County Health Department ` 210 Hospital Street P.O. Box 848 -�Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Phil Strupe Builders Inc. Address: 217 Riverwood Drive City: Lewisville State/Zip: NC 27023 Phone #: (336) 945-4410 Address/Road #: 147 Sawgrass Drive Advance NC 27006 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: *Water Supply: PUBLIC *CDP File Number 123841-1 E9-000-00-291 County ID Number. Evaluated For. NEW Township: �roperty Owner: Phil Strupe Builders Inc. Address: 217 Riverwood Drive City: Lewisville State/Zip: NC 27023 Phone #: (336) 945-4410 Subdivision: Sawgrass Phase: 1 Lot: 291 Directions Hwy 801 Turn into teak Valley, left on Seay Drive. Right on Silverrod , then left on Sawgrass. Lot is on left *IP Issued by. *System Classification/Description: TYPE II A- CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: SaproliteSystem? OYes QNo Design Flow: 4 8 0 * PUMP TO GRAVITY Pump Required? Distribution Type: Q Yes QNo Soil Application Rate: 0 . 3 *Pre Treatment: Drain field Nitrification Field No. Drain Lines Total Trench Length Trench Spacing: Trench Width: Aggregate Depth: 1 6 0 0 Sq. ft. 4 4 0 0 It. — 9 Inches O.C. Feet O.C. 3 Inches — , f Feet inches Minimum Trench Depth: 3 6 Minimum Soil Cover. 2 4 Maximum Trench Depth: 3 6 Maximum Soil Cover: a 4 Inches *System Type: INFILTRATOR QUICK 4 STANDARD Installer: Frank Transou Certification #: 2771 *EH S: 2140 - Nations. Robert Date: 0 9/ 1 0/ 2 0 1 5 Inches Approval Status Inches M Approved C1 Disapproved Inches / bep_:te_ Uziua: •tnp _ JJO � fJT -J1UJ 1... [- A)'['L.OYftON GOt1 SITE EVAL1A1T101/iktI-ItOVEIttFNf Pf nA11T S ATC Davic County Health C :pattment En1ironnJW4fa1HQ7A, iSOC6017 P.O. Boz 848/210 HosIttal StToot Mockavino, HC 27020 (336) 751-871:0 •e•YJJI'ORTANT•oo TRIS APPLICATION CANNOT BE PRDC.iSSED UNLP„',S ALti TSS REQ=1xD 17JFORHATION IS PROVIDED. Rotor to tho INFOWW::O27 BULLP.'1' N for inatrueti(mv. A. Have to be Dtued 0,1'%�tJ1,� 1y al1e� 6iso:ifi!t 41• �y.fpc'•ciMt,a Peraan �S0 Jt;vts Halling iddrass J-1 G 1 ' �! • Noss Phone City/mato/:Zr 1 •♦ i' �++^ ".) G4 b. 1 %i S+ -I ✓'71 G(s /a�u_alne,. pLjona S �is. -7'1471 V 1 1. Hams on Pea.it•/:tTC It Dltfuteat I— Above nalling Addraad .5� lv�{ tY ty/::Cato/Zip `� 1. Application For: ta �0 s1te Evaluation. O I.q_.roveaat Permit/ATC 13 Doti. e. 5yaLow to Servire, td Rouse ❑ Mobil* Noma 13 Du: t.nean 0 mduotry tJ Othow S- Type srstam requ•stodt �Cwtveneional 13 coavoatlonal ::od111cd ❑ inrtovativo t3accented a. I.Z�sicaidanco:/ Paopl• r) a IIcdr�a/::4s 0 Dathrtlo2M edDlahvaa8er f/Carba7e Dlap»al lGMaahing fucbine Id:uasstent/Pluneing QDaseaeat/tro PIw,L1nD 7. If Duolnesa/Iaduatry /Otbarr verify type If People I sinks / coralee I ::Aovsrs 0 arin•:L I Hater Male— IF moD:ERVICE: a scats Eatimated Wter Unago (7allena per dayl 0. Typo of water salply. 1/County/City Q xo.l1 ❑ Co=unty S. Do yw eutsalpate addtttona or espmuiolss of the facility 11tis syst. at is ialended to scrvc? ❑ Yes An If yes, \that lype? •••h'JJ`0RfAN7•''• CLtErIT_ )1UST COAIPLETC• 1'nZ i QuzArr) CAOrmtTY INFOlRMATION "QtILS ED' 111:1.011'. EifLcraPI.ATorS1TIIPIAriAIt roESURAln7r;obvlL:Niant svlthTHIS AI` UCATION. I'ruperly Dimensions _ ,u is.' 1Ylt1TL NIZECTIONS (rrum Aleetwitte) to 1'AOI'Elt'M. Tax. Office IT* r. St7 - S l-' 5� f + Proper(y Address: Road Nmnc_� V lke City/vp Ifrtl a Subdiclsian provide inform326ov, as follows: 112111: Section: Block. vt: Date ho re corners !lagged: This is to certify llutt the infunmilion prorided is correct to the best of try k otvledga I understand Thal any pernul(s) issued Hereafter are subject to suspension or revocation, if the site plaus ori. fended use ehaage, or if me ruforutatiun submitted in 11211 appliealiun is ralsiricd a1 changed. /, afro, uudrrsrdndrhdr: nor rmponsible jorall dtutivii1icurrrdfrdm Wrdpplicatiat. I.hereby,*girecouse2d tolite AuthtirizedRepresentallyeof.!wcDaricCountyllcal)1LDepartment _ to euter spun abort described properly located iii Davie County and amt (/ to conduct all (eslUC procedures as ummzry to determine the site suitptritit� DiVIT _C �� _ SIGNATURE— TANS AREA MAY BE USED FOR DIL\11= YOUR SYfri PLAN (foeludc :dl of the following: Existing and proposed property lines and dintenslons, structures, sellmcla, and septic locations). Site ltcyisif Cbarge Da1c(s): ClreulNolInearion Date: EHS: Sign given ,Account No. lteviscd DCIV) (05/0.7 luvnim leo. r, �J t tr.�i.�• SITE CLASSIFICATION: VS EVALUATION BY. V � f '` "`"��, ►'�/ LONG-TERM ACCEPTANCE RATE. c ' 3 OTHER(S) PRESENT: REMARKS: V*J Oil _ —1 ( D r - - -- LEGEND Landscape 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 lu � 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 1`Ioies 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 Classification - S(suitable), PS (provisionally suitable), U(unsuitable) ti LTAR - Long-term acceptance rate - gal/day/f2 :NI)CHD 05105 (Revised) Landscape position - DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section NUMNTexture ----- group Soil/ Site Evaluation APPLICANT INFORMATION W. _Wym OW29—f-A PROPERTY INFORMATION Account M 990003765 Tax PIN/EH #: 5871-25-2458.31 Billed To: Oak Valley Associates Limited Partne Subdivision Info: Oak Valley Lot # 31 Reference Name: Texture - Location/Address: Oak Valley Boulevard -27006 Proposed Facility: Residence Property Size: see map Date Evaluated:1017-71�S Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut SITE CLASSIFICATION: VS EVALUATION BY. V � f '` "`"��, ►'�/ LONG-TERM ACCEPTANCE RATE. c ' 3 OTHER(S) PRESENT: REMARKS: V*J Oil _ —1 ( D r - - -- LEGEND Landscape 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 lu � 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 1`Ioies 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 Classification - S(suitable), PS (provisionally suitable), U(unsuitable) ti LTAR - Long-term acceptance rate - gal/day/f2 :NI)CHD 05105 (Revised) Landscape position ��0----- • ' • • ' NUMNTexture ----- group Consistence W. _Wym OW29—f-A Mineralogy HORIZON 11 DEPTH Texture - rlr���rv���■����� WAR=11?mMineralogy ���o� —NNOWED1�10 HORIZON II DEP`FH SM11 10 '0 Texture group -�r�rr,������ Consistence Mineralogy �. Mom. HORIZON IV DEPTH Texture group Consistence Mineralogy SOIL WETNESS CLASSIFICATION SITE CLASSIFICATION: VS EVALUATION BY. V � f '` "`"��, ►'�/ LONG-TERM ACCEPTANCE RATE. c ' 3 OTHER(S) PRESENT: REMARKS: V*J Oil _ —1 ( D r - - -- LEGEND Landscape 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 lu � 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 1`Ioies 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 Classification - S(suitable), PS (provisionally suitable), U(unsuitable) ti LTAR - Long-term acceptance rate - gal/day/f2 :NI)CHD 05105 (Revised) CDP Fite Number 123841 -1 County ID Number:. E9-000-00-291 Septic Tank Manufacturer. Shoaf Lat. STB: 760 Long: , Gallons: 1000 Installer: Frank Transou Date: 0 5/ a a/ a $ 1 5 Certification #: 2771 ' *EH S: 2140 - Nations, Robert *Filter Brand: POLYLOK PL -122 With Pipe Adapter ST Marker: El Yes 2 No Date: 0 9/ 1 0/ 2 0 1 5 Reinforced Tank: ❑ Yes ® No Approval Status =® Approved ❑ Disapproved Piece Tank: El Yes ®No Pump Tank Manufacturer. Shoaf Installer. Frank Transou PT: 42 Certification 4: 2771 Gallons: 1250 *ENS: 2140 -Nations, Robert Date: 0 3 / 1 3 / 2 0 1 5 Date: 0 9/ 1 0/ 0 1 5 RiserSealed ® Yes ❑ No Riser Height: ® Yes ❑ No (Min.6 in.) Approval Status I : einforced Tank: 13 Yes LD NO D Approved ❑ "Disapproved 1 Piece Tank: (] Yes ❑ No Supply Line a inchdiameter Installer: Frank Transou 7POipeize: gfh: 1 5 0 feet Certification #:2771 *EH S: 2140 - Nations, Robert cedule: 40 Pressure Rated 9 Yes ❑ No Date: 0 9/ 1 0/.2 0 1 5 Approved fittings B Yes ❑ No Approval Status 1 , Approved ❑ Disapproved Pump Requirerngnt Type: z0eier Installer Frank Transou ('Pump Dosing Volume: — Gal Certification #: 2771 Draw Down: Inches *EHS: 2140 -Nations, Robert *Chain: STAINLESS Date: 0 9/ 1 0/ 2 0 1 4 Valves Accessible ❑ Yes ❑ No Flow Adjustment valve F*1 Yes ❑ No Check -valve ® Yes ❑ NO ApprovatStatus- PVC unions (] Yes ❑ No Approved ❑ Disapproved. Vent Hole Q Yes Anti -siphon Hole ❑ Yes ❑ ❑ No No CDP File Number 123841-1 IR 1-101iti33I1I1i-11411I County ID Number: E9-000-00'291 N EMA 4X Box or Equivalent 2 Yes ❑ No Installer: Frank Tansou Box 12 inches Above Grade Q Yes ❑ NO 2771 Certification #: Box Adj. To Pump Tank Q Yes ElNO Conduit Sealed 2 Yes ❑ No *EH S: 2140- Nations, Robert Pump Manually Operable Q Yes ❑ No *Activation Method: PIGGYBACK Date: 0 9/ 1 0 / 2 0 1 5 Alarm Audible (p Yes ❑ N o Approval Status ® Approved ❑ Disapproved Alarm visible p Yes ❑ No 2140 - Nations, Robert *Operation Permit completed by: Authorized State Agent:,k , ,A Ile Date of Issue: 0 9 / 1 0 / 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 It A. sewage septic system. Rule .1961 requires that a Type TYPE II A. septic system meet the following criteria: Minimum System Review By The Local Health Department: NIA Management Entity: OWNER Minimum System Inspection/Maintenance Frequency ByCertified Operator: WA 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 fora home/business owner must maintain avalid 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 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 tong 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. OHand Drawing Olmport Drawing **Site Plan/Drawing attached.** M OPERATION PERMIT Davie County Health Department CDP File Number: 123841 -1 210 Hospital Street County File Nu ber: E9 -000-M291 P.O. Box 848 Mocksville NC 27028 Date: f �I V Construction Authorization 1 ` Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville, NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Address/Road #: 147 Sawgrass Drive Advance, NC 27006 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: *Water Supply: PUBLIC Property Owner: Address: City: State/Zip: Phone #: For Office Use Only 'CDP File Number 123841-1 County ID Number: E9-000-00-291 Evaluated For: NEW PERMIT VALID UNTIL: 11/15/2018 Phil Strupe Builders Inc. 217 Riverwood Drive Lewisville NC. 27023 (336)945-4410(336)945-9309 Location & Site Information Subdivision: Sawgrass Phase: NEW Lot: 291 'Site Classification: Provisionally Suitable Applicant: Phil Strupe Builders Inc. Address: 217 Riverwood Drive City: Lewisville W/SINGLE EFFLUENT PUMP State/Zip: NC 27023 Nitrification Field Phone #: home: (336) 945-4410 cell :(336) 945-9309 Pump Required: OX Yes O No Address/Road #: 147 Sawgrass Drive Advance, NC 27006 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: *Water Supply: PUBLIC Property Owner: Address: City: State/Zip: Phone #: For Office Use Only 'CDP File Number 123841-1 County ID Number: E9-000-00-291 Evaluated For: NEW PERMIT VALID UNTIL: 11/15/2018 Phil Strupe Builders Inc. 217 Riverwood Drive Lewisville NC. 27023 (336)945-4410(336)945-9309 Location & Site Information Subdivision: Sawgrass Phase: NEW Lot: 291 'Site Classification: Provisionally Suitable Design Flow: 480 24 Inches Soil Application Rate: 0.3000 'System Classification//Description: TYPE III B. SYSTEM W/SINGLE EFFLUENT PUMP 'Proposed System: 25% REDUCTION Nitrification Field Sq. ft. No. Drain Lines Pump Required: OX Yes O No Total Trench Length: 400 ft. 1,000 Gallons O Inches O.C. Trench Spacing: - OFeet O.C. 8Feet Inches Trench Width: - Aggregate Depth: inches Directions Hwy 801 Turn into Oak Valley, left on Seay Drive. Right on Silverrod , then left on Sawgrass. Lot is on left bpecmcanons Minimum Trench Depth: 24 Inches Minimum Soil Cover: Inches Maximum Trench Depth: 36 Inches Maximum Soil Cover: Inches 'Distribution Type: PUMP TO GRAVITY Septic Tank: 1,000 Gallons 1 -Piece: OYes 0 No Pump Required: OX Yes O No O May Be Required Pump Tank: 1,000 Gallons 1 -Piece: O Yes OX No GPM —vs-- ft. TDH Dosing Volume: Gallons Grease Trap: Gallons Pre -Treatment: ONSF OTS -I OTS -II Septic Tank Installer Grade Level Required: 0 1 Oil 0 111 0 IV CDP File Number: 123841 Repair System *Site Classification: Provisionally Suitable Design Flow: 460 Soil Application Rate: 0.300 *System Classification/Description: TYPE III B. SYSTEM W/SINGLE EFFLUENT PUMP *Proposed System: 25% REDUCTION Nitrification Field Sq. ft. No. Drain Lines Total Trench Length: 400 ft. County ID Number: E9-000-00-291 Maximum Soil Cover: Inches *Distribution Type: PUMP TO GRAVITY Pump Required: © Yes 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. *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 may be 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 Applicant/Legal Resps. Signature Required ? O Yes Q No Applicant/Legal Reps. Signature: Date: *Issued By: Daywalt, Andrew Date of Issue: 11/15/2013 Authorized State Agent: Malfunction Log O Yes O Hand Drawing O Import Drawing Total Time:(HH:MM) **Site Plan/Drawing attached.** Page 2 of 2 Inches O.C. Trench Spacing: — Feet O.C. Trench Width: — BInches Feet Aggregate Depth: Inches Minimum Trench Depth: 24 Inches Minimum Soil Cover: Inches Maximum Trench Depth 36 Inches Maximum Soil Cover: Inches *Distribution Type: PUMP TO GRAVITY Pump Required: © Yes 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. *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 may be 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 Applicant/Legal Resps. Signature Required ? O Yes Q No Applicant/Legal Reps. Signature: Date: *Issued By: Daywalt, Andrew Date of Issue: 11/15/2013 Authorized State Agent: Malfunction Log O Yes O Hand Drawing O Import Drawing Total Time:(HH:MM) **Site Plan/Drawing attached.** Page 2 of 2 'CONSTRUCTION For Office Use Only AUTHORIZATION *CDP File Number 123841-1 Davie County Health Department E9-000-00-291 tY P County ID Number: 1 210 Hospital Street Evaluated For: NEW P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax: 336-753-1680 1 1/ 1 5/ 2 0 1 8 Applicant: Phil Strupe Builders Inc. Property Owner: Phil Strupe Builders Inc. Address: 217 Riverwood Drive Address: 217 Riverwood Drive City: Lewisville City: Lewisville State2ip: NC 27023 State2ip: NC 27023 Phone #: (336) 945-4410 Phone #: (336) 945-4410 / Address/Road #: 147 Sawgrass Drive Advance NC 27006 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: *Water Supply: PUBLIC Subdivision: Sawgrass Phase: 1 Lot: Zq Directions Hwy 801 Tum into Oak Valley, left on Seay Drive. Right on Silverrod , then left on Sawgrass. Lot is on left System Specifications '`Site Classification: PS Saprolite System? OYes ONo Design Flow: 4 8 0 Soil Application Rate: 0 3 *System Classification/Description: TYPE III B. SYSTEM W/SINGLE EFFLUENT PUMP *Proposed System: 250,o REDUCTION Nitrification Field No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: Aggregate Depth: Sq. ft. 4 0 0 ft. Minimum Trench Depth: 2 4 Inches Minimum Soil Cover. Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: Inches *Distribution Type: PUMP TO GRAVITY Septic Tank: 1 0 0 0 Gallons 1 -Piece: OYes ONo Pump Required: OYes ONo OMay Be Required Pump Tank: 1 0 0 0 Gallons 1-Piece:OYes ONo GPM—vs— ft. TDH —8 Inches O.C. Feet O.C. Dosing Volume: _ Gallons W Slnches — Feet Grease Trap: Gallons inches Pre -Treatment: ONSF OTS -1 OTS -11 Septic Tank Installer Grade Level Required: 01 011 0111 OIV Page 1 of 3 CDP File Number 123841 - 1 Repair *Site Classification: PS Design Flow: A R n County ID Number: E9-000-00-291 irea:vTes vivu vivu, but nab kvanaore S Soil Application Rate: 0 3 *System Classification/Description: TYPE III B. SYSTEM MINGLE EFFLUENT PUhIP 'Proposed System: 25% REDUCTION NRrification Field Sq. ft. No. Drain Lines ❑ Open Pump System Sheet Trench Spacing: _ Q Inches O. O Feet O.C. Trench Width: _ Q Inches o Feet Aggregate Depth: inches Minimum Trench Depth: 2 4 Inches Minimum Soil Cover. Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: Inches *Distribution Type: PUMP TO GRAVITY Total Trench Length: 4 0 0 ft. Pump Required: Yes ()No OMay Be Required 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 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 maybe Issued at the same time the Improvement Permit issued (NCGS 130A -336(b)). "the Installation has not been completed during the period of validity of the Construction Permit, the Information submitted In theappiication for a permit or Construction Authorization Is found to have been Incorrect, falsified or changed, or the site is attered, 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, rhes, 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: 2244 - Daywalr. Andrew Date of Issue: 1 1 / 1 5 / 2 0 1 3 Authorized State Agent: a 4 d Malfunction Log Oyes OHand Drawing Olmport Drawing Total Time:(HH:1.11.1) **Site Plan/Drawing attached.** 0 1 Hours 0 0 Minutes Page 2 of 3 S-8 - CAS issued - new CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number: 123841-1 ` 210 Hospital Street E9-000-00-291 P.O. Box 848 County File Number: Mocksville NC 27028 Date: 1 1/ 1 5/ 2 0 1 3 Olnch Drawing Drawing Type: Construction Authorization Scale:. OBlock ON/A APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Box 848/210 Hospital Street ��� R+ CUMD Mocksville, NC 27028 I?j (336)753-6780/ Fax (336)753-1680 10141 ApoiWion tion/lmprovement Permit ❑ Authorization To Construct (ATC) ❑ Both Type oApplication: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility 'IMPORTANT'" *IMPORTANT* * * THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name /7 l �✓ ��� ldecsS Contact Person �'►.l S���r Address 11 ; ✓ e/'WJ ";W A- Home Phone Property Address City/State/ZIP C' W S V' e- /1/C 9L d i Business Phone X36 - �% s - ";.3d!� Email (2 Subdivision Name(if applicable Email: ��1•'� S��'✓e `1��- �ic�y . �•z... Name on Permit/ATC ififferent than Above 1 ✓ i^ t V, Mailing Address re..- K _ I I I- - - City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flavved A0 —/S-- / 3 NOTE: A survey plat or site plan must accompany this application. Included: ate Plan ❑Plat(to scale) f r (Permit is' vlid 60 m9pths wit site plan, n9 expiration with complete plat.) Are there any existing wastewater ystems on the site? Owner's Name -.& u `k) Does the site contain jurisdictiona wetlands? Phone Number Are there any easements or right- f -ways on the site? Owner's Address go/0, —City/State/Zip /U' C. 2 Si5/- u Property Address &Jve City t/4r.k / Lot Size S Y30,4 Tax PIN# ;,v "94-`f 2— 00 go 24 Subdivision Name(if applicable e� ^-Ss -- Sectio Directions To Site:W y gt> 1 ✓ i^ t V, , re..- K _ I I I- - - -- --- If the answer to any of the following uestions is "Yes",supporthlg documentation must be attached: Are there any existing wastewater ystems on the site? _Yes \ Does the site contain jurisdictiona wetlands? Yes V_No Are there any easements or right- f -ways on the site? )CNo Is the site,stbjept to approval by another public agency? _Yes ATO Will wastewater other than domestic sewave be venerated? _Yes Yes �io IF RESIDENCE FILL OUT THE BOX BELOW # People -!— # Bedrooms _7_ # Bathrooms L Garden Tub/Whirlpool es ❑No Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No 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: elConventional ❑Accepted ❑Innovative ❑Alternative ❑Other. Water Supply Type: WCounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes w 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 falsified or changed. I hereby grant right of entry to 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 flagging or slicing the house/facility location, proposed well location and the location of any other amenities. Site Revisit Charge Property ow is or owners legal representative signature Date(s): Client Notification Date: Date EHS: Sign given ❑Yes ❑No Revised 11/06 Account # 1-Z3 CIJ41 Invoice # C , y3 a 4-lelvc...6-er W( )?U06