2248 Farmington RdDAVIE COUNTY ENVIRONMENTAL HEALTH
' P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680
REPAIR OPERATION PERMIT
Account #: 990001313 Tax PIN/EH #: C500000060
Billed To: William Brock Subdivision Info:
Address: 2248 Farmington Road Location/Address: 2248 Farmington Rd -27006
City: Mocksville Property Size: 2.06 AC
Reference Name:
Proposed Facility: REPAIR
**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:y� S.T. Manufacturer Tank DatTank Size -/
Pump Tank Size
System Installed By�Eor aA Aek24 E.H. Specialist:&&W 6#ate: Z�o
GPS Coordinate:
L41
ter,
5
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 #: 990001313
Billed To: William Brock
Reference Blame:
Proposed Facility: REPAIR
Tax PIN/EH #: C500000060
Subdivision Info:
LocationiAddress: 2248 Farmington Rd -27006
Property Size: 2.06 AC
ATC Number: 5837Site Type: ❑New �2epair ❑Expansion
**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 2 # Bathrooms # People 2 Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size G( Type of Water Supply: Ocounty/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow (GPD) 2-40 Tank Sizer" 1 AL. Pump Tank GAL.
�n1`� t`
Trench Width do Max. Trench Depth Rock Depth Linear Ft. 151w
Site Modifications/Conditions/Other:
Contact the Davie Con
8:30 — 9
Environmental Health
al inspection of this
'Mb
0
10!
between
Environmental Health Specialist Date:
DCHD 11/06 (Revised)�L�Ckqu''\vvyaw
1611312011
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME i I l i min, Emck &- PHONE NUMBER aq T ' 3Q,�Q
ADDRESS 22A 4 Gzrrn i ncLSl /?-J SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS (Q - _.__"NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTEDn Z�l/ 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 OF OWNER OR AUTHORIZED AGENT
Rev. 1/93
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VI C4 5831