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2076 Hwy 601S (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: Fred O Ellis Address: 6943 NC Hwy 801 S City: Mocksville State/Zip: NC 27028 Phone #: (336) 909-0717 Property Loca Address/Road #: Subdivision: 2076 Us Hwy 601 S Mocksville NC 27028 Structure: RESTAURANT # of Bedrooms: # of People: *Water Supply: PUBLIC *IP Issued by: *CA Issued by: 2140 - Nations, Robert Design Flow: 6 0 0 Soil Application Rate: 0 a 7 5 *CDP File Number 198050 - 2 County ID Number: Evaluated For: REPAIR �ownship: //Property Owner: Fred O Ellis Address: 6943 NC Hwy 801 S City: Mocksville State/Zip: NC 27028 hone #: (336) 909-0717 ion & Site Information Phase: Directions 601 South Lot: *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 Nitrification Field a 1 8 a Sq. ft. No. Drain Lines 7 Total Trench Length: 7 a 7 ft. Trench Spacing: 9 0Inches O.C. (9 Feet O.C. Trench Width:3 OInches (9 Feet Aggregate Depth: 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: Randy Miller Certification #: 1128 *EHS: 2140 - Nations, Robert Date: 0 a/ a 3/ a 0 1 7 Approval Status X❑ Approved ❑ Disapproved CDP File Number 198050 - 2 County ID Number: Manufacturer: Shoaf se tic i anK PT: Manufacturer: a inch diameter Lat. Gallons: 1500 4 ( 5 feet Long: Date: STB: 1/ 1 8 / x 0 1 7 Riser Sealed Gallons: Yes ❑ Installer: Riser Height: Date: / / Certification #: Reinforced Tank: d Yes ❑ *EHS: \ 1 Piece Tank: *Filter Brand: N/A ❑ NO Approved ❑ Disapproved Flow Adjustment Valve X Yes ❑ No ST Marker: ❑ Yes ❑ NO Date: Yes Reinforced Tank: ❑ Yes ❑ NO Approval Status Approval Status X Yes ❑ El Approved El Disapproved 1 Piece Tank: El Yes El NO Yes ❑ Manufacturer: Shoaf Supply Line PT: 353 a inch diameter Installer: Gallons: 1500 4 ( 5 feet Certification #: Date: 0 1/ 1 8 / x 0 1 7 Riser Sealed 0 Yes ❑ No Riser Height: Pressure Rated Yes ❑ NO (Min. 6 in.) Reinforced Tank: d Yes ❑ NO \ 1 Piece Tank: 0 Yes ❑ NO Pump Tank Installer: Randy Miller Certification #: 1128 *EHS: 2140 - Nations, Robert Date: 0 a/ a a/ a 0 1 7 Approval Status 0 Approved ❑ Disapproved / Pump Type: zoeler Supply Line Installer: Pipe Size: a inch diameter Installer: Randy Miller Pipe Length: 4 ( 5 feet Certification #: 1128 Inches *EHS: 2140 - Nations, Robert *Schedule: 40 Pressure Rated X❑ Yes ❑ No Date: 0 a/ a 3/ a 0 1 7 Approved fittings X❑ Yes ❑ NO Valves Accessible Approval Status Yes ❑ No ❑X Approved ❑ Disapproved Flow Adjustment Valve X Yes ❑ No / Pump Type: zoeler Installer: Rusty Miller Dosing Volume: - Gal Certification #: 1129 Draw Down: Inches *EHS: 2140 - Nations, Robert *Chain: ROPE 0 a/ a a/ a 0 1 7 Date: Valves Accessible ❑X Yes ❑ No Flow Adjustment Valve X Yes ❑ No Check -valve ❑X Yes ❑ NO Approval Status PVC unions X Yes ❑ No X Approved ❑ Disapproved Vent Hole ❑X Yes ❑ NO Anti -siphon Hole ❑X Yes ❑ No Page 2 of 4 CDP File Number 198050 - 2 County ID Number: NEMA 4X Box or Equivalent ❑X Yes ❑ NO Installer: Rusty Miller Box 12 inches Above Grade ❑X Yes ❑ NO 1129 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: 0 a/ a 3/ x 0 1 7 Method: PIGGYBACK Alarm Audible ® Yes Alarm Visible 0 Yes 2140 *Operation Permit completed by_ Authorized State Owner/Applicant Signature: Approval Status El No El No 0 Approved ❑ Disapproved ns, Robert Date of Issue: 0 a/ a 3/ a 0 1 7 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 Drawing Drawing Type: Operation Permit tJ CDP File Number: 198050 - 2 County File Number: 27028 '?S`� Date: O Inch Scale: 1 , 0 , 0 , (9 Block i 0 N/A s. 4 a J V .0 Page 4of4 <�_ �-. I , P1 P2 P3 F 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: 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