112 Courtney RdAccau�t #
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DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680
990004344
Gregory Lewis Beck
REPAIR PERMIT
Residential Repair
REPAIR OPERATION PERMIT
T�x �I�€:EN �:
S���idi�i: iarl i�fz7:
LacaiioniA�d���ss:
. i�cc��er#.y Size:
B30000006405
Courtney Rd Lot # 1 and 2
112 Courtney Road-27028
** ** T �uance of this Operation Permit shall indicate the system described on the ATC has been installed
��� n c�o �m�p ance�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. Manufacturer Vt Tank Date / Tank Size /
, . Pump Tank Size �y���
System Installed By: E.H. Specialist: te:�����y`--_�l/
' GPS Coordinate:
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 CONSTRLJCTION
}�ccou�t �: 990004344 "�ax F�l�€iEH #: B30000006405
�iilc� ic�: Gregory Lewis Beck Su�adivi�iati infc�: Courtney Rd Lot # 1 and 2
t��€er�E�ce Rla��e: REPAIR PERMIT ;. Loc�iiioniAd+�r�ss: 112 Courtney Road-27028 :.
Propc��Qc� Fa�:ility: Residential Repair - - �fo�������. OIVew ,�Repair ❑Expansion `
E`�'ffN�{['�'ibi?ffhis5�fifhorization to Construct (ATC) MUST BE ISSUED,tiy 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 chanee.
Residential Specifications: # Bedrooms 2# Bathrooms # People� Basement� Basement plumbing�
Non-Residential Specifications: Facility Type # People # Seats •
Square Footage(or Dimensions of Facility) '
Lot Size Type of Water Supply: ❑County/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow (GPD)� y� Tank Size��AL. Pump Tank �'S"` GAL.
Trench Width� Max. Trench Depth Rock Depth�///�' Linear Ft.��ac� � �
Site Modifications/Conditions/Other:
T 7'T ���i�G���
Contact the avie County Environmental He�lth Section for final inspection of
8:30 — 9:30a.m. on the day of installation. Telephone #(336)751-
u
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v�
system between
Environmental Health Specialist Y • Date: ZO�`
DCHD 11/06 (Revised)