Loading...
134 Fairfield RdATC Number: 5940 **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. ag System Type: S.T. Manufacturer Tank Date Tank Size f$'OU Pump Tank Size i Bedrooms: 5 System Installed By: Installer# Date: GPS Coordinate: A Environmental Health Speciali DCHD 11/06 (Revised) Date: i7 L v_v �o� DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 OPERATION PERMIT Account #: 990005884 Tax PIN/EH #: L507OA0020 Billed To: Lurline Clark Subdivision Info: Deference Name: EXPANSION PERMIT LocationiAddress:: 134. Fairfield Road -27028 Proposed Facility: Residential Expansin Properly Size:= 0.86Acre ATC Number: 5940 **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. ag System Type: S.T. Manufacturer Tank Date Tank Size f$'OU Pump Tank Size i Bedrooms: 5 System Installed By: Installer# Date: GPS Coordinate: A Environmental Health Speciali DCHD 11/06 (Revised) Date: i7 L v_v �o� 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 #: 990005884 Tax PIN!EH #: L5070A0020 Billed To: Lurline Clark Subdivision Into: Reverence Narne: EXPANSION PERMIT Location!Address:. 134 Fairfield Road -27028 . Proposed Facility: Residential Expansin Property Size: , 0.86 Acre ATC Number: 5940 Site Type: ❑New ❑Repair lExpansion **NOTE** This Authorization 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 # 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) f • O Tank Size 2S _ GAL. Pump Tank,-" GAL. Trench Width 3b Max. Trench Depth �� Rock Depth Linear Ft.1160' 25'% 0jI(.Gttoo Site Modifications/Conditions/Other: Contact the Davie County Environmental Health Section for final inspection of this system between Environmental Health Specialist Tlriurn 1 1 mA (uP6QP,t) L C E Davie County H ealth Department MAY 3 2.0 P. Environmental Health Section BY: P.O. Box 848 1. 210 Hospital Street�� I Courier # : 09-40-06 Pb ;01!71k'V Mocksville, NC 27028 � j,', NY � Phone: (336) -753 - 6780 a), : GJ 7 2(% c (336) -753-1680 � �Z ON-SITE WASTEWAT MXERWICA (Check One) Replacement Remodelin Reconnec e - Name: () 2 dQ // < nn Phone Numb r 7 S� ' 3 ��3 (Home) Mailing Address: 114 IL�j/(J(� 3�Cr %� 'if �(Work) DetailedDirectionsTo Site: �V! j Property Address: // �i Please Fill In The Following Information About The EXISTING Facility: 1-5070AaoZd ©,Ao t'K� r Name System Installed Under: 0ro S e P }� ( c �Z Type Of Facility:h !_ 9 f r Fh � Date System Installed (Month/Date/Year): -7US ? Number Of Bedrooms: 3 Number Of People: 7 Is The Facility Currently Vacant? Yes Any Known Problems? Yes <n If Yes, If Yes, For How Long?. Please Fill In The Following Information About The NEW Facility: Type Of Facility: Y1 h�, I c. rrA nl `�., Number Of Bedrooms: S Number of People Pool Size: f\ Q Garage Size: A \ Other: Requested By: tjGtwN & /3 o c O"' Date Requested: r/726 (Stei ature) For Environmental Health Office Use Only Approved Disapproved � , Comments: VI -MAI -5-id A/ 7 P/rii'li� �q d /y'�ZI P_!I ' /(/S�i�'6!•�UI - 6-7, Environmental Health Specialist Date: *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Paymen Cash Check Moneyorder # Amount:$_ /00,10,0— Date: 3 / l L Paid By: ` 11 y a- CC�/IM12-I- Received By: T Account #: , tT 7}54-% Invoice #: (,fi( APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/ Fax (336) 753-1680 Application For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility * * * IMPORTANT" THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to beBilled 0. Q0 , Contact Person W u 6 Qr� Billing Addresso°� icy C,Z C -t Home Phone City/State,/ZIP S i t � Business Phone 1%� 3 ti - 0 Name on Permit/ATC if Dierera than Above Mailing Address City/State/Zip "Date House/Factlity Comers NOTE: A survey plat or site plan must accompany this application. Included: 0 Site Plan ❑Plat(to scale) (Permit i valid or 60 months wij{h, site plan, no expiration with complete plat.) Owner's Name_ ( 't'j-t C )a Phone Ntmnnber I S Owner's Address I3LI 5q 'I ;' ii City/State/Zip_h%uv1(.,S011 he 1.• U Property Address City. Lot Size Tax PIN# I Subdivision Name(if applicable) Section/Lot# Directions To Site: i% 0 ( S 1 Yr i PesA aityl, ,Cr otA `l�c� f>` t m, fir. i rri'[ (/R, 1 L� If the answer to any of the"following questions is "yes", supportii Are there any existing wastewater systems on the site? Does the site contain jurisdictional wetlands? Are there any easements or right-of-ways on the site? Is the site subject to approval by another public agency? Will wastewater other than domestic sewage be generate `RYes ONo ❑Yes`ikNo ""NYes ONo ❑Yes' No ❑YesRNo IF RESIDENCE FILL OUT THE BOX BELOW # People _C' # Bedrooms 7 # Bathrooms Garden Tub/Whirlpool ❑Yes %No Basement: ❑Yes 3tNo Basement Plumbing: ❑Yes�No IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type:'�ACounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, what type? `A No This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I rstand that I am responsible for the proper identification and labeling of property lines and comers and locah/jrd ,p0,Vf,W$g or staking the house/facility location, proposed well location and the location of any other amenities. OLE V perty owners or owner's legal representative signature Site Revisit Charge r-% Date(s): Client Notification Date: Date EHS: Sign given ❑Yes ONo Account # Revised 11/06 Invoice # 4 • APPLICATION FOR PRIVATE WELL PERMIT Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780./ Fax (336)753-1680 * * *IMPORTANT* ** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. APPLICANT INFORMATION Name WQU j VIS &q CY Address &661 N i &1�1e, k C* City/State/ZIP Name on Permit if Different than Above Mailing Address Contact Person Wo wy t &o►w Home Phone y 11 _Business Phone 3Gq - 5 (Q6 "1 City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat (to scale) Owner's Name Luv Jin , oar y Phone Number 3293 Owner's Address ) N '-tiY �R�e ld City/State/Zip PropertyAddress me, City Lot Size Tax PIN# 1. 50 46S60Z-O Subdivision Name(if applicable) Section/Lot# Directions To Site: DEVELOPMENT INFORMATION Permit Type: New Well Well Repair Well Abandonment V Other (specify) Facility Type: Residential v1 Food Service Church Commercial Other Are There Any Septic Systems Currently On The Site? YES ,/ NO Do You Intend To Install A New Septic System On This Site? YES NO TERMS AND CONDITIONS: This application must be accompanied by a plat or site plan of the property that includes the existing and proposed property lines with dimensions, the specific location of the facility and any existing or future appurtenances, the location of any existing septic system, sewer lines, water lines, any existing water supplies and any surface waters. The applicant is responsible for identifying and marking the property lines and corners. The applicant is responsible for making the site accessible. By signing this application, the applicant signifies that they understand the terms and conditions and that they give permission for Davie County Environmental Health representatives to perform necessary field evaluations and procedures deemed necessary to determine the best location for a well. Signed s/3�/�Z Date Site Revisit Charge Date(s): Client Notification Date: EHS: 7/30/09 Account # Invoice #