118 Dallas Ln OPERATION PERMIT or fice use Only
Davie County Health Department 'CDP File Number 123019- 1
210 Hospital Street 13.000-00.015
P.O.Box 848 County ID Number.
AM `s Mocksville NC 27028 Evaluated For: REPAIR
Phone:336-753-6780 Fax: 336-753-1680 Township:
r
pplicant: Floyd Greene Property Owner: Floyd Greene
ddress: 732 Green Hill Road address: 732 Green Hill Road
dy: Mocksville CRY Mocksville
State/Zip: NC 27028 State/Zip: NC 27028
Phone::: Phone:::
Property Location & Site Information
Address/Road »: Subdivision: Phase: Lot:
118 Dallas Lane
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 64 W. turn right before I -40
K of Bedrooms: 3
of People:
'Water Supply: NIA
'IP Issued by. 'System Classification/Description:
TYPE 11 A.COW SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
'CA issued by: 2244-Dayvvalt,Andre:v
Saprolite System? QYes QNo
Design Flow: 3 6 0 Distribution Type: GRAVITY Pump Required?
QYes (DNo
Soil Application Rate: 0 . 3 'Pre-Treatment:
Drain field
7drificationld Sp ft. 'System Type: INFILTRATOR QUICK4 STANDARD
Installer: randy miGerand son
Total Trench Length: 2 6 0 ft. Certification:::
Trench Spacing: _ ()Inches O.C. Y
Feet O.C. EH S: 224.3-Daytivalt,Andrew
Trench Width: _ Oinches
Feet Date: 0 8 / 2 6 / 2 0 1 3
Aggregate Depth: inches
Minimum Trench Depth: Inches
t.linimum Soil Cover. Inches Approval Status
t.taximum Trench Depth: Inches EEO] proved O Disapproved
t.taximum Soil Cover:
Inches
l46t44 g8g9oo1[3 TNwiCe �1P7/
CDP File Plumber 123019 - 1 Septic Tank County ID Number: 13.000-00-015
ranufacturer existing Lat.
STB: Long:
Gallons: Installer:
Date:
/ / Certification 4-:
'EH S: 2211-Day watt.Andrew
'Filter Brand:
ST Marker: ❑ Yes ❑ No
Date:
Reinforced Tank: ❑ Yes ❑ NO Approval Status
,,--','Piece Tank: ❑ Yes ❑ No ❑ Approved❑ Disapproved
Pump Tank
Manufacturer. Installer:
PT: Certification;::
Gallons: 'EHS:
Date: / / Date:
Riser Seated ❑ Yes ❑ No
Riser Height: ❑ Yes ❑ No (Min.6 in.)
Approval Status
Zeinforced Tank: ❑ Yes E] No El Approved 11 Disapproved
1 Piece Tank: ❑ Yes ❑ No
Supply Line
CPipe Size: inch diameter Installer:
Pipe Length: feet Certification:::
'Schedule: 'ENS:
Pressure Rated ❑ Yes ❑ No Date:
Approved fittings ❑ Yes ❑ No Approval Status
❑ Approved ❑ Disapproved
Pump e uire ent
Pump Type: Installer:
Dosing Volume: — Gal Certification
Draw Down: Inches *EH S:
'Chain: Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ N O
Check-valve ❑ Yes ❑ NO Approval Status
PVC Unions ❑ Yes ❑ No ❑ Approved ❑ Disapproved
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole ❑ Yes 0 No
123019 - 1 13-000-00.015
CDP File Number County ID Number:
Electric Equipment
rBo
EIAA4X Box or Equivalent ElYes ElNo Installer.x 12 inches Above Grade ❑ Yes ❑ No
Certification#:
Box Adj.To Pump Tank ❑ Yes ❑ No
Conduit Sealed ❑ Yes ❑ NO 'EH S:
Pump Manually Operable ❑ Yes ❑ NO
'Activation Method: Date:
Approval Status
Alarm Audible El Yes ElNo ❑ Approved❑ Disapproved
Alarm Visible ❑ Yes ❑ No
2244-Dayn:alt.Andrew
"Operation Permit completed by:
Authorized State Agent: Date of Issue: 0 8 / 2 6 / 2 0 1 3
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 11 A. sewage septic system.
Rule .1961 requires that a Type TYPE 11 A. M septic system meet the following criteria:
h1inimum System Review ByThe Local Health Department: NA
1.1anagement Entity: OWNER
Minimum System InspectioniMaintenance Frequency By Certified Operator:
NA
Reporting Frequency By Certified Operator. NA
Rule .1961 requires that a Type IV and V septic systems designed for a home/business owner must maintain a valid contract
wrth 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.
QHand Drawing Qlmport Drawing
**Site Plan/Drawing attached.**
Total Time:(HH:1.11d)
Activity Code: S-19 20.1-OP issued NEW Type 11 Ouick 4 0 1 Hours 0 0 minutes
OPERATION PERMIT 123019 - 1
Davie County Health Department CDP File Number:
210 Hospital Street 13.000.00-015
P.O.Box 848 County File Number:
Mocksville NC 27028 Date:
0Inch
Di-awing Drawing Type: Operation Permit ON/A Scale: O = ft.
aJ-
cwt
OPERATION PERMIT F*CDPFileNumber
ice use nv
A�ti�zv Davie County Health Department 123019- 1
210 Hospital Street 13.000-00.015
P.O.Box 848 mber:
... Mocksville NC 27028 Evaluated For: REPAIR
Phone:336-753-6780 Fax: 336-753-1680 Township:
Applicant: Floyd Greene Property owner: Floyd Greene
Address: 732 Green Hill Road Address: 732 Green Hill Road
City: Mocksville City: Mocksville
State/Zip: NC 27028 State/Zip: NC 27028
Phone#: Phone;::
Property Location &Site Information
Add
resstRoad #: Subdivision: Phase: Lot:
118 Dallas Lane
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 64 W. turn right before 1 -40
#of Bedrooms: 3
#of People:
"Water Supply: N.'A
`IP Issued by. 'System Classification/Description:
TYPE II A.COW SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
'CA issued by: 2244-Day►.alt,Andrew
Saprolite System? QYes ONO
Design Flow: Pump Required?
3 6 0 Distribution Type: GRAVITY-SERIAL
QYes (DNo
Soil Application Rate: 0 3 'Pre-Treatment:
Drain field
rNftrificatiiron Field Sq. ft. 'System Type: INFILTRATOROUICK4STANDARD Lines Installer: randy miBerand son
Total Trench Length: 2 6 0 n- Certification»:
Trench Spacing: _ Inches O.C. y
Feet O.C. EH S: 2244-Dayn:alt,Andrew
Trench Width: Inches
SFeet Date: 0 8 / 2 6 / 2 0 1 3
Aggregate Depth: inches
Minimum Trench Depth:
Inches
Minimum Soil Cover. Inches Approval Status
t,taximum Trench Depth: Inches El Approved❑ Disapproved
Maximum Soil Cover:
Inches
CDP File Number 123019 - 1 CID Numb13-000-00-015
Septic Tank ounty er:
F.lanufacturer. existing Lat.
STB: Long: ,
Gallons: Installer:
Certification
Date:
'EHS: 2244-Daywalt,Andrea
'Filter Brand:
ST Marker: ❑ Yes ❑ No Date: -
Reinforced Tank: ❑ Yes ❑ NO Approval Status
Piece Tank: ElYes E3No E] Approved ❑ Disapproved
Pump Tank
t.lanufacturer. Installer:
PT: Certification r:
Gallons: 'EHS:
Date: / / Date:
RiserSealed ❑ Yes ❑ No
Riser Height: ❑ Yes ❑ No . (1..,lin.6 in.)
Approval Status
forced Tank: ❑ Yes ❑ No ❑ Approved❑ Disapproved
1 Piece Tank: ❑ Yes ❑ No
Supply Line
Pipe Size: inch diameter Installer:
Pipe Length: feet Certification:::
'Schedule: 'ENS:
Pressure Rated ❑ Yes ❑ No Date:
Approved fittings ❑ Yes ❑ No Approval Status
❑ Approved ❑ Disapproved
Pump e ur n
rPump Type: Installer:
sing Volume: Gal Certification»:
Draw Down: Inches 'EH S:
'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
• CDP File Number 123019 - 1 County ID Number: 13-000-00-015
Electric Equipment
rBo
Eh1A4X Box or Equivalent ElYes ❑ No Installer:
x 12 inches Above Grade. ❑ Yes ❑ No
Certification--u:
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 ❑ Yes ❑ No
2244-Daywalt.Andrew
'Operation Permit completed by:
Authorized State Agent: % Date of Issue: 0 8 2 6 2 0 1 3
This system has been installed in compliance with applicable PJC General Statutes:Article 11,Chapter 130A, Rules for
Sewage Treatment and Disposal, 15A NCAC 18A.1900 et. Seq., and all conditions of the Improvement Penn it and
Construction Authorization.This property is served by a TYPE 11 A. sewage septic system.
Rule .1961 requires that a Type TYPE 11 A. septic system meet the following criteria:
Minimum System Review By The Local Health Department: wA M
Management Entity: OWNER
f,linimum System InspectionjUaintenance Frequency By Certified Operator:
NIA
Reporting Frequency By Certified Operator: NIA
Rule .1961 requires that a Type IV and V septic systems designed fora homelbusiness 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 homelbusiness 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 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.
OHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Total T ime:(H H aA t,1)
Activity Code. S-19204 OP issued NEW Type It Quick 4 0 1 Hours 0 0 J.1inutes
. OPERATION PERMIT
Davie County Health Department CDP File Number: 123019 - 1
210 Hospital Street 13.000-00.015
P.O.Box 848 County File Number:
klocksville NC 27028 Date:
Olnch
Di-aging Drawing Type: Operation Permit Scale: OBiock
ONin
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• CONSTRUCTION
For Office Use Only
�= AUTHORIZATION `CDP File Number 123019- 1
"-`' Davie County Health Department County ID Number: 13.000.00.015
210 Hospital Street Evaluated For: REPAIR
P.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 0 8 / 2 6 / 2 0 1 8
Applicant: Floyd Greene Property Owner: Floyd Greene
Address: 732 Green Hill Road Address: 732 Green Hill Road
City: Mocksville Cly: Mocksville
State/Zip: NC 27028 State/Zip: NC 27028
Phone::: Phone:::
Property Location & Site Information
Address/Road #: Subdivision: Phase: Lot:
118 Dallas Lane
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 64 W. tum right before 1 -40
R of Bedrooms: 3
r of People:
"Water Supply: NIA
System Specifications
fainimum Trench Depth: 2 4
CSitessification: Ps Inches
tltinimum Soil Cover.System? OYes ONo Inches
egnlow: 3 6 U F.laximum Trench Depth: 3 ,6 Inches
Soil Application Rate: Maximum Soil Cover: Inches
0 3
'System Classification/Description: 'Distribution Type: GRAVITY-SERIAL
TYPE II A.COW SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
_ Gallons
'Proposed System: 250%REDUCTION 1-Piece: Oyes ONo
Pump Required: OYes ONo OfAay Be Required
N trification Field
Sq. ft. Pump Tank: Gallons
No. Drain Lines 1-Piece: OYes ONo
Total Trench Length: 3 0 0 It. GPhi—vs-- ft. TDH
Trench Spacing: Inches O.C.
817eet O.C. Dosing Volume: _ Gallons
Trench Width: Inches
8Feet Grease Trap: Gallons
Aggregate Depth: inches
Pre-Treatment: ONSF OTS-1 OTS-II
Septic Tank Installer Grade Level Required: 01011 0111 OIV
Page 1 of 3
. CDP File Number 123019 - 1 County ID Number: 13-000-00-015
l' Q Open Pump System Sheet
Repair System Required:OYes ONO ONO, but has Available Space
epair System
Trench Spacing: Inches O.C,
*Site Classification: Feet O.C.
15A NCAC 18kw1945 *'�` * 8Fe teS
Design Flow;
Aggregate Depth:
Soil Application Rate: inches
Minimum Trench Depth:
'System Classification/DescriRe* pair
Area Exempt- Inches
Inches.
(aaximum Trench Depth:
*Proposed System: Inches
Maximum Soil Cover:
Nitrification Field Inches
Sq. ft.
No, Drain Lines 'Distribution Type:
Total Trench Length: ft Pump Required: ()Yes ONo OtAay 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 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 bevalid for a person equal to the period of validity of the Improvement Permit,not
to exceed five years,and may be issued at the sametime 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(g)).The person owning or controlling the system shalt 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
ApplicantrLegal Reps. Signature- Date:
*Issued By: 2244-Daywalt.Andrew Date of Issue: 0 8 2 6 2 0 1 3
Authorized State Agent: trtalfunction Log OYes
OHand Drawing ()Import Drawing Total Time:(HH-111.1)
**Site Plan/Drawing attached.**
1 Hours_ 0 0 r.linutes
Page 2 of 3
S-10-CNS issued-repair
CONSTRUCTION AUTHORIZATION
Davie County Health Department CDP File Number: 123019- 1
210 Hospital Street 13-000-00.015
P.O.Box Bas County File Number:
Mocksville NC 27028 Date: 0 8 / 2 6 / 2 0 1 3
Q Inch
Drawing Drawing Type: Construction Authorization Scale: . 0N/A .c = ft.
Q N/A
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Pana 3 of 3