353 Fork Bixby RdAccount #:
Billed To:
Reference Name:
Proposed Facility:
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680
990000940
Dana Beach
Repair Permit
Residential -Repair
REPAIR OPERATION PERMIT
Tax PINIEH #:
Subdivision Into:
LocationiAddress:
Propefty Size:
Tr1 DDDoDDgaO i
5778-21-0587
353 Fork Bixby Road -27006
1.05 Acres
ATG1M The Mfiance 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. aa
I XiSI`'�y
System Type: / S.T. Manufacturer„/ Tank Date T nk Size d6o
Pump Tank Size
System Installed By:�E.H. Specialist: Date:
GPS Coordinate:
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61 4je.
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DCHD 11/06 (Revised)
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t DAVIE COUNTY ENVIRONMENTAL HEALTH
• P.O. Box 848/210 Hospital Street �1
Mocksville, NC 27028 �I
(336)753-6780 /Fax # (336)753-1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #:
990000940
Billed To:
Dana Beach
Reference Fume:
Repair Permit
Proposed Facility:
Residential -Repair
Tax PINIEH #: 5778-21-0587
Subdivision Into:
LocalioniAddress: 353 Fork Bixby Road -27006
Properly Size: 1:05 Acres
Site Type: ❑New VRepair ❑Expansion
ATC Number: 5734
**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 I # People-S_Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size 1. O `J Type of Water Supply: C�County/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow (GPD) y Tank Size GAT . Pump Tank GAL.
Trench Width -36 t Max. Trench Depth 3 o Rock Depth A11 Linear Ft. 0 15-
SiteModifications/Conditions/Other:;,s statr in r , ;;(°r,! n, ais�o IL°�ol.��7: �-►
1 >
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.
_`
Environmental Health Spec
DCHD 11/06 (Revised)
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5%.LfAt 4-t' 3 4
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Date: d ( I — k
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) _
NAME n �� i� -piggy PHONE NUMBER
ADDRESS I SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
5t 'A `
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY' M NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY Co SPECIFY PROBLEM OCCURRING
v
DATE REQUESTED'— U < < INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge. and that I understand 1 am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1193
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http://maps.co. davie.nc.us/GoMaps/map/map.cfm?CFID=4129&CFTOKEN=61640881 2/10/2011
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