186 Kent LnOPERATION PERMIT
Davie County Health Department
° ¢ 210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Randall D. Grubb
Address: 130 Kent Lane
City: Mocksville
State/Zip: NC 27028
Phone #: (336) 998-7699
Address/Road #:
186 Kent Lane
Mocksville
Structure:
# of Bedrooms:
# of People:
*Water Supply:
*CDP File Number 245241 - 1
5755345461
County ID Number:
Evaluated For: NEW
�ownship:
/Property Owner: Randall D. Grubb
Address: 130 Kent Lane
City: Mocksville
State/Zip: NC
Phone #: (336) 998-7699
Property Location & Site I
Subdivision:
NC 27028
SINGLE FAMILY
2
2
N/A
*IP Issued by:
*CA Issued by: 2140 - Nations, Robert
Design Flow: a 4 0
Soil Application Rate: 0 3
Nitrification Field
No. Drain Lines
Total Trench Length
Trench Spacing:
Trench Width:
Aggregate Depth:
Wrl
27028
Phase: Lot:
Directions
Hwy 601 S. left on Becktown Rd. right on Kent Lane
*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.
a
a04ft.
9 0Inches O.C.
®Feet O.C.
3 6 (gInches
0 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: 2325 - Mitchell, Brittany
Date: 0 1/ 0 3/.1 0 1 8
Approval Status
0 Approved ❑ Disapproved
CDP File Number 245241 - 1
/ Manufacturer: shoat
STB:
760
PT:
Gallons:
Gallons:
1000
/
Riser Sealed
Date:
1
1/
0 5/
a 0 1 7
*Filter Brand:
❑ Yes
Inches
ST Marker:
❑
Yes
❑
NO
Reinforced Tank:
❑
Yes
❑
No
\ 1 Piece Tank:
❑
Yes
❑
NO
Manufacturer:
Pump Type:
PT:
Gallons:
Date:
/
Riser Sealed
❑ Yes
Riser Height:
❑ Yes
Reinforced Tank:
❑ Yes
\ 1 Piece Tank:
❑ Yes
/ Pipe Size:
Pipe Length:
*Schedule:
Pressure Rated ❑ Yes
Approved fittings ❑ Yes
❑ No
❑ NO (Min. 6 in.)
❑ No
❑ No
County ID Number: 5755345461
clog UT17 7
Lat.
Long:
Installer: Rusty Miller
Certification #: 1129
*EHS: 2325 - Mitchell, Brittany
Date: 0 1/ 0 3/ x 0 1 8
Approval Status
❑X Approved ❑ Disapproved
Pump Tank
Installer: Rusty Miller
Certification #: 1129
*EHS:
Date:
Approval Status
❑ Approved ❑ Disapproved
Supply Line
inch diameter Installer: Rusty Miller
feet
Certification #: 1129
*EHS:
❑ NO Date:
❑ NO Approval Status
❑ Approved ❑ Disapproved
/
Pump Type:
Dosing Volume:
-
Draw Down:
Inches
*Chain:
Valves Accessible
❑
Yes
❑
No
Flow Adjustment Valve
❑
Yes
❑
No
Check -valve
❑
Yes
❑
No
PVC Unions
❑
Yes
❑
No
Vent Hole
❑
Yes
❑
NO
Anti -siphon Hole
❑
Yes
❑
No
Installer: Rusty Miller
Gal Certification #: 1129
*EHS:
Page 2 of 4
Date:
Approval Status
❑ Approved ❑ Disapproved
CDP File Number 245241 - 1
County ID Number: 5755345461
NEMA 4X Box or Equivalent
❑
Yes
❑
NO
Installer:
Rusty Miller
Box 12 inches Above Grade
❑
Yes
❑
NO
1129
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
2325 - Mitchell, Brittany
*Operation Permit completed by:
Authorized State Agent: Date of Issue: 0 1/ 0 3/ a 0 1 8
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 111 G. sewage septic system.
Rule .1961 requires that a Type TYPE 111 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
N
I UI
QX t S ri c 4'ive
LOIS
Page 4of4
CDP File Number: 245241 - 1
County File Number: 5755345461
Date: 01/03/,2018
O Inch
Scale: O Block = ft.
O N/A
N
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
5755345461
Page 4 of 4 P1 P2 P3
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Septic Tank:
Pump Tank:
Supply Line:
Pump Requirements:
Electrical Equipment:
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