150 Eaton RdLt1v %-%JV1V11 L'1v VlAV1V1V1D1V 1 HL riDtUL tri
P.O. Box 848/210 Hospital Street
t Mocksville, NC 27028
(336)753-6780/Fax #(336)753-1680
REPAIR OPERATION PERMIT
t
Accnunt #: 990001933 Tax PIE�1iE1 I #: J5090A0012
Billed To: Martha Rollins Subdivision Info: Rental Property Lot #
Reference Name: REPAIR PERMIT Locatio iAddress` 150 Eaton Road-27028
Proposed Facility: Residental-Rental Property Siz4: 1.9 Acres
v.
ATC WuMr: TWrance of this Operation Permit shall indicate the system described on the ATC has been installed
in comp lance 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. Manufacture rM Tank Date '`� Tank Size
Ppmp Tank Size .i t2
System Installed By:f'�1lQt('lY1AVl .O klj:j E.H. Specialist:
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 CONSTRUCTION
�t
Account #: 990001933 Tax PIN!EH #: J509OA0012
Billed To: Martha Rollins Subdivision Into: Rental Property Lot #
Reference Nance: REPAIR PERMIT LocationiAddress: '150 Eaton Road -27028
Proposed Facility: Residental-Rental PrON46 �: ❑IfieVp§pair ❑Expansion
* '5R 7
N, QTffib'-iThis6aeyhorization 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 chanSe.
Residential Specifications: # Bedrooms Z- # Bathrooms # People 2 Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats_
Square Footage(or Dimensions of Facility)
Lot Size ,"l QL Type of Water Supply: (County/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow (GPD)"790 Tank Size- V 0 Pump Tank GAL.
Trench Width Max. Trench Depth Z L Rock Depth/J tt4 Linear Ft. 200gd
Contact the Davie County
830 — 9:30:
Environmental Health Speciali
DCHD 11/06 (Revised)
Jection Ior Ilnal Inspectimi o1 tins systein oetween -
lation. Telenhone # (336)751-8760.
Date:
L116d h
:Ak-4,+'kW
' DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
3PTLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME /�-i��l�' 0 Y','5 PHONE NUMBER Z
ADDRESS �/ GZd (IiI ��(� SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
C) �j ki6k�
DATE SYSTEM INSTALLE/D, NAME SYSTEM INSTALLED UNDER 6:IW AI&'
TYPE FACILITY 5W �' Y- NUMBER BEDROOMS NUMBER PEOPLE SERVE
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRINGItaGz uea .
DATE REQUESTED / I I &/ / Z INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application.
SIGNATURE (/OFOWNER OR AUTHORIZED AGENT
Rev. 1f93 -#-I " /��1 . /�
GoMAPS - Davie County NC Public Access
MOCKSVILLE I I
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GATON RD + li
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***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 sotfrces. 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.
El
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Thursday, January 12 2012