391 Cherry Hill 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 #: 990002367 Tax PINIEH#: M60000004403
Billed To: Terry Burton Subdivision.lnfo:
Reference Name: REPAIR PERMIT LocalioniAddress: :391 CherryHill Road-27028
Proposed Facility: Residential Repair Property Size:,., litl 85 Acres
ATC Number: 5937 -
**NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC has been installed
in compliance with Article I 1 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. n —J�
System Type:_S.T.Manufacturer y Tank Date Tank Size
Pump Tank Size Bedrooms
System Installed By: gf-014 'jvc D� Installer#: , Date:
GPS Coordinate: vy
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I96
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Environmental Health Specialist: Date:
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 #: 990002367 Tax PIN!1=H#: M60000004403
Billed To: Terry Burton ;Subdivision Info:
Reference Name: REPAIR PERMIT Location/'Aftegs 191 Chquy Hill Road-27028
e
Proposed Facility: Residential Repair PropeA �Z 0 %5 Sgit ❑Expansion
**NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental
ATgeNMPHion�lR7to.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 #Bathrooms 2 #People BasementO Basement plumbingO
Non-Residential Specifications: Facility Type #People #Seats
I . Square Footage(or Dimensions of Facility)
Lot Size]lp��fL_ Type of Water Supply: gCounty/City OWell OCommunity Well
System Specifications: Design Wastewater Flow(GPD) Tank Size (S� AL.Pump Tank GAL.
Trench Width Max. Trench Depth Rock Depth.A)1)4 Linear Ft.
Site Modifications/Conditions/Other:
Contact the Davie County Environmental Health 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 Specialist Date:
DCHD 11/06(Revised) .� �e /l-)O
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Oil/ -h 373 611.ezu mit
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• DAVIE COUNTY ENVI ONMENTAL HEALTH SERVICE REQUEST
APPLICATION IP/ATC OSWW REPAIR
Name Tury Rttdovt Telephone Number
AddressAh,�( Zi�
=
Mailing Address (if differen om above)
Email Address:
Subdivision Name Lot#
Directions 14q( 000D D Y 03
1, 1?5-46
Date System Installed Name System Installed Under e Cl Sett-lon
Type Facility Number Bedrooms J� Number People S rved 3
Type Water SupplyC0Specific Problem Occurring
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
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DAVIE„COUNTY,HEALTH_,DEPARTMENT ..,. ,,,. . '
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130-Article 13C)
OWNER OR CONTRACTOR ,' ",:; '' + DATE PERMIT
LOCATION ^,l _ .',x' 555
nr., Ef" Fit' f'J.'s: t5`ri c x S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE ❑ MOBILE HOME BUSINESS ❑
i House Trailer 800 Gal. 40g_Sgy._,Ft.
NO. BEDROOMS NO. BATHROOMS Two Bedroom House ..,_,800 Gal•`J !&00 Sq.
GARBAGE DISPOSAL UNIT YES ❑ NO ❑ Three Bedroom House 900 Gala 900 Sq.,, Ft.
AUTO. DISHWASHER YES ❑ NO ❑ Four Bedroom House 1000 Gal. 1200 Sq. Ft.
AUTO. WASH. MACHINE YES ❑ NO ❑ 'PA0 w•�1laY �k V' riaS. N"A
SITE SUITABLE YES ❑ NO [3SIZE OF TANK t!'•-�a gal. ���ItA grade. S-t-nkes . 'Tc cry 'arSl.
NITRIFICATION FIELD sq. ft. • , ra v�c�- Fa'��`�Y' i r.S�a��� p ��
DEPTH OF STONE IN LINES: i,- 'r p a p p* S e G 7Z'n1zi.
WATER SUPPLY: ' Individual ❑ . Public ❑'
7s 30 p, v'-•
IMPROVEMENTS PERMIT BY C. INSTALLED BY Am W"J IAR D
CERTIFICATE OF COMPLETION BY , Date
(8/16/73) *Construction must mply with all other applicable State and local regulations
LOT AREA
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