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186 Chinquapin Rd (3)
M DAVM COUNTY ENVIRONMENTAL 14RALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax 4 (336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 99.0003475 Tax PIS€/Ehl #: 5813-95-5691 Billed To: Jimmy Gentle Subdivision-lntc: Reference Name: REPAIE PERMIT i.ocati'on Ad&6§s:` =186 Chinquapin Road -27028 Proposed Facility: Residential Repair Pehpdtityr&z�P:- VAcre Site Type: ❑New Comair ❑Expansion ATC Number: 5746 **NOTE** This Authorization to Conslxuct (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 ind Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE PEARS. This ATC is subject to revocation if site plans, plat or the intended use change. Residential. Specifications: # Bedrooms ) /# Bathrooms 1 # People BasementC�'Basement plumbingEl Non -Residential Specifications: Facility Type _ # People # Seats y Square Footage(or Dimensions of Facility) Lot Size 4 C:C..- Type of Water Supply:.❑County/City. we -ii ❑Community Well System Specifications: Design Wastewater Flow (GPD) 4.0 Tank SizeXLTlnp Tank GAL. Ir / Trench Width Max. Trench Depth b Rock Depth Linear Ft. !� Site Modifications/Conditions/Other: '�° - *39:c`i• ted ill .:l hik [mi". Contact the Davie County EnviuronmentaI flefilth Section for finollm-sVely bri of this syste,n 8:30 - 9:30a.m. on the day of installation. Telephone # (336)751-8760. , z DCHD 11/C �� r r Specialist 040 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753•-1680, qq REPAIR OPERATION PERMIT .Account #, 990003475 -Tax. PiN/EH #: 5813-95-5691 BilledTo: Jimmy Gentle Subdivision Into: Reference Name: REPAI0-PERMIT LocationlAddress:• 186 Chinquapin Road -27028' Proposed Facllity;. Residential Repair - Properly $ize': • 1�Acre AT ftFj*`fih§7A§ance of this Operation Permit shall indicate the :system described on the ATC has been; installed in compliance with Article I 1 of G.S. Chapter 130A, Section .1900. "Sewage Treatment and Disposal Systems," but shalt in NO WAY be taken as a. guarantee that the system will function satisfactorily for any given period of time.r=x�s�r system Type: v{'i S.T. Manufacturer /tank Date�Tank Siz Pump Tank Size. System Installed By ;*k 411A"640SjP 'L/G E.H. Specialist: Date: GPS I� to DCHD 11106 (Revised) 1 dot 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 ***IMPOI{TANP** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. APPLICANT INFORMATION Name il�l wr m t r --r. We - ContactPorson71-Priji/it/ r7ne� ch�- Address �G Home Phone, City/Stat O L � � �BusinessPhone 334 `l9,4 • SOS Name on Permit if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or siteplan must accompany this application. Included: ❑ Site Plan ❑Plat (to scale) Owner's Named Phone Number Owner's Address City/State/Zip Property Address City Lot Size Tax PIN# Subdivision Name(if applicable) Section/Lot# Directions To Site: —RWV V __ 4 0/ A] 40 SNA i n tl [lz" i kI OL) DEVELOPMENT INFORMATION Permit Type: New Well V1 Well Repair Well Abandonment Other (specify) Facility Type: Residential 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. 7/3 0/09 Date Site Revisit Charge Date(s): Client Notification Date: EHS: Account # Invoice # LO Si d 7/3 0/09 Date Site Revisit Charge Date(s): Client Notification Date: EHS: Account # Invoice # l All data is provided as Is without warranty or guarantee of any kind either expressed or Implied Including but not Ilmited to the Implied (W warranties of merchantability orfitness for a particular use. All users of Davle County's GIS website shall hold harmless the County of 1 N� Davis, North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out Printed:Jan 20 2© 5 of the use or Inability to use the GIS data provided by this website.