742 Fairfield 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: Mary Poole
Address: 742 Fairfield Rd
City: Mocksville
State/Zip: NC 27028
Phone #: (336) 284-4758
Property Loca
Address/Road #: Subdivision:
742 Fairfield Rd
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People: 4
*Water Supply: EXISTING WELL
*IP Issued by: 2399 - Eldridge, Tiffany
*CA Issued by: 2399 - Eldridge, Tiffany
Design Flow: 3 6 0
Soil Application Rate: 0 a 7 5
Nitrification Field
No. Drain Lines
Total Trench Length
Trench Spacing:
Trench Width:
Aggregate Depth:
*CDP File Number 249061 - 1
5746854718
County ID Number:
Evaluated For: REPAIR
�ownship:
/Property Owner:
Mary Poole
Address:
9025 HWY 601
City:
Salisbury
State/Zip:
NC
Phone #:
(336) 284-4758
ion & Site Information
28147
Phase: Lot:
601 S Left on 801 left on Will Boone Rd left on
Fairfield Rd Property on left
*System Classification/Description:
TYPE III G. OTHER NON-CONV. TRENCH SYSTEMS
Saprolite System? "'Yes X No
*Distribution Type: NSA Pump Required?
0 Yes X No
*Pre -Treatment:
Drain field
1 3 0 9 Sq. ft.
4
3a8ft.
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: 2399 - Eldridge, Tiffany
Date: 0 4/ 1 Q/ a 0 1 8
Approval Status
0 Approved ❑ Disapproved
(`nP Pilo Nh imhcr 249061 -1
/ Manufacturer:
STB:
Supply Line
Manufacturer:
Pipe Size:
Gallons:
PT:
Dosing Volume:
Pipe Length:
Gallons:
Date:
Date:
*EHS:
*Filter Brand:
❑
Yes
Riser Height:
❑
ST Marker:
❑
Yes
❑
NO
Reinforced Tank:
❑
Yes
❑
NO
1 Piece Tank:
❑
Yes
❑
NO
rl-.. a. , i n n 1. 5746854718
5eotic I anK . ww ' "y — I Nul I
❑ No
❑ No (Min. 6 in.)
❑ No
❑ No
Lat.
Long:
Installer:
Certification #:
*EHS:
Date:
Approval Status
❑ Approved ❑ Disapproved
Pump Tank
Installer:
Certification #:
*EHS:
Date:
Approval Status
❑ Approved ❑ Disapproved
Supply Line
Manufacturer:
Pipe Size:
inch diameter
PT:
Dosing Volume:
Pipe Length:
Gallons:
Certification #:
Date:
*EHS:
Riser Sealed
❑
Yes
Riser Height:
❑
Yes
inforced Tank:
❑
Yes
1 Piece Tank:
❑
Yes
Approved ❑ Disapproved
rl-.. a. , i n n 1. 5746854718
5eotic I anK . ww ' "y — I Nul I
❑ No
❑ No (Min. 6 in.)
❑ No
❑ No
Lat.
Long:
Installer:
Certification #:
*EHS:
Date:
Approval Status
❑ Approved ❑ Disapproved
Pump Tank
Installer:
Certification #:
*EHS:
Date:
Approval Status
❑ Approved ❑ Disapproved
/ Pump Type:
Supply Line
Pipe Size:
inch diameter
Installer:
Dosing Volume:
Pipe Length:
feet
Certification #:
*Schedule:
*EHS:
Pressure Rated ❑ Yes
❑ NO
Date:
*EHS:
Approved fittings ❑ Yes
❑ NO
Approval Status
❑
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
El
Yes
Ll
No
Anti -siphon Hole
E]
Yes
E]
No
Page 2 of 4
CDP File Number 249061 - 1
5746854718
County ID Number:
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
ElYes
❑
NO
2399 - Eldridge, Tiffany
*Operation Permit completed by:
Authorized State Agent: Date of Issue: 0 4/ 1 a/ 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
- -Z � I -- I - �\
Ile
36fl Rr�
CDP File Number: 249061 - 1
County File Number: 5746854718
Date: / /
O Inch
Scale: O Block
O N/A
•I - I - I -I-17
Page 4 of 4 P1 P2 P3
OPERATION PERMIT
Davie County Health Department
210 Hospital Street CDP File Number:
P.O. Box 848 5746854718
County File Number:
Mocksville NC 27028
Date:
Click below to import an image from an external location: Drawing Type: Operation Permit
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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