965 Beauchamp Rd DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
REPAIR OPERATION PERMIT
Account #: 99000587.1 Tax PINIEH#: E00000001
Billed To: Frank Myers Subdivisian.Info:
Reference Name: REPAIR PERMIT Loc9tionfAddrres .'965 Beauchamp Rd-27006
Proposed Facility: Residential Repair i,, Property Size:- 4i 57 Acres
ATC Number: 5921
**NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC has been installed
in compliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"
but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of
time.
System Type:S.T.ManufacturerPlcl� Tank Date / Tank Size
Pump Tank Size ./ J Bedrooms
System Installed By: GL ell-f Inspector#: Date: . /Z
GPS Coordinate:
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Environmental Health Specialist: Date: �� Z
DCHD 11/06(Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780/Fax#(336)753-1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990005871 Tax PIN,EH : E00000001
Billed To: Frank Myers ` Subdivision Info:
Reference Name: REPAIR PERMIT !ocationiAddress:. 965 Beauchamp Rd-27006
Proposed Facility: Residential Repair Prope'rty Size: 4.57 Acres
Si e Type: ONew Wepair ❑Expansion f
AT*QK q,rhiMulhorization to Construct(ATC)MUST BE ISSUED'by the Davie County Environmental
Health Section prior to.issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A
Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat
or the intended use change.
Residential Specifications: #Bedrooms 2. #Bathrooms t #People 2 BasementO Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size t" ,S)c,L Type of Water Supply: JgCounty/City ❑Well OCommunity Well
System Specifications: Design Wastewater Flow(GPD) f yD Tank SizeQCc25�cj GAL.Pump Tank
Trench Width3_6LMax. Trench Depth.24L Rock Depth IfJf,4 Linear Ft. 26�c
Site Modifications/Conditions/Other: �o
Contact the Davie County Environmental Hefilth Section for final inspection of this system between
8:30–9:30a.m.on the day of installation. Telephone#(336)751-8760.
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Environmental Health Specialis Date: � —
DCHD 11/06(Revised)
of 16 b e. - kf
' DAVIE COUNTY ENVIRONMENTAL HEATTft SERVICE RteQUEST
APPLICATION IP/ATC OSWW REPAIR q!1/-q&jsf
NameAjozs Telephone Number 940-5Z51
Address lh " li Ci 2
Mailing Address (if different from above) 4-00— O 11
Email Address: E'--20000000 ,57
Subdivision Name Lot#
i e
Dctions / a vowee- elv& i�'ytd r U. keN odo
j)eauoLi6Lmo O S 6 aa,rie-� 04,
Date System Installed Name System Installed Under
Type Facility Number Bedrooms Number People Served
Type Water Supply W&11 Specific Problem Occurring t-1DNer'P-k - les
Wale( Corniria lhuoh keA) 0oNefile
Date Requested Info Taken By
THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY
KNOWLEDGE,AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED
FROM THIS APPLICATION.
Signature of owner or Authorized Agent
Initial Fee Date REHS
Revisit Charge Date Reason
Revised 2-2011
be
•� '='`, ,."IDAVIE COUNTY E IRONMENTAL HEAITf4 SERVICE ReQUEST
APPLICATION IP/ATC OSWW REPAIR eel j ql1/.r &jy
A Name fl(�HJ�I` _Z"5 Telephone Number
Address
Mailing Address (if different from above)
Email Address: 'L.20000660( r
Subdivision Name Lot//#
Di ections �� (,�/ vQfU@C 1 &VIO irdld/G &U. keP A
Date System Installed ��Jr" 7/ . - Name System Installed Under
Type Facility Number Bedrooms Number People Served
Type Water Supply We 1 :�, +` � �pecific Problem Occurring N6'fe4G
Date Requested' ::.` l' Info Taken By
THIS IS TO CERTIFY THAT THE JINFQ, 4 "ATION PRORVIDED IS CORRECT TO THE BEST OF..MY
KNOWLEDGE.-AND THAT I UNDERS'T'AND THA' 1� ,:E1M,RESPONSIBLE FOR ALL CHARGES INCURRED
FROM THIS APPLICATION.
Signature of owner or Authorized Agent
Initial Fee Date REHS
Revisit Charge Date Reason ''
Revised 2-2011 f i.
GoMAPS - Davie County NC Public Access
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Wednesday,April 25 2012
***WARNING:THIS IS NOT A SURVEY!***
This map is prepared for the inventory of real property found within this jurisdiction,and is compiled from recorded
deeds,plats,and other public records and data.Users of this map are hereby notified that the aforementioned public
primary information sources should be consulted for verification of the information contained on this map.The
County and mapping company assume no legal responsibility for the information contained on this map.