577 Gordon Dr1.
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680
REPAIR OPERATION PERMIT
Account #: 990005708 Tax PIN/EH #: 5862-83-5725
Billed To: Mary Smith Subdivision Info:
Reference Blame: REPAIR PERMIT Location/Address:. 577 Gordon Drive -27006
Proposed Facility: Residential Repair Property Size: .28 Acre
ATC*jpjqjV� 590
Tfie 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. {{ ]
rSystem Type: 11� S.T. ManufacturerPXiSA1' Tank Date ,Vll Tank Size
Pump Tank Size —
System Installed By:6/'Il�/1 /h ar�i�� E.H. Specialist: kiVdlte: r
GPS Coordinate:
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DCHD 11/06 (Revised)
0
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680
REPAIR IMPROVEMENT PERMIT
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990005708 Tax PINIEH #: 5862-83-5725
Billed To: Mary Smith Subdivision Info:
Reference Blame: REPAIR PERMIT LocationiAddross: 577 Gordon Drive -27006
Proposed Facility: Residential Repair Property, Size:, .28 Acre
p,T PV- Ihis-I oAuthorization 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 IP/ AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat
g 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 Sizeo 2tiLZC Type of Water Supply: 17County/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow (GPD)90 Tank Size(7AAS AL. Pump Tank � GAL.
Trench Widths Max. Trench l)eptlL� Rock Depth& Linear Ft. ijg ZS`7,01 1 *
. 1 ,,,.`
Site Modifications/Conditions/Other:
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)753-6780.
Environmental Health Speciali
DCHD 11/06 (Revised)
5 f �X i5
6,k
Date:
oe/l 909
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)?e_NP
NAME (1446110rJ6 PHONE NUMBER
ADDRESS 6-1-100 I-WQAJ LlZ, Ahame" SUBDIVISION NAME .4�
LOT #
DIRECTIONS TO SITE Iry D/ a 6 M10jZ16 W 7� O U!a 1140 A W 0 (30 016 A) d (I Ve v rlj V g�, , /A lea
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY 13 NUMBER BEDROOMS NUMBER PEOPLE SERVED 12/1
TYPE WATER SUPPLY Ma HIL SPECIFY PROBLEM OCCURRING �i MeS
i
DATE REQUESTEINFORMATION 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
5109 _ _ �vv. 7-782,
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