2812 Hwy 801SDAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680
REPAIR OPERATION PERMIT
Account #: 990005681 Tax PIN!EH #: 5789 -20 -4814 -REPAIR
Billed To: Mark Philpott Subdivision Info:
Reference Name: REPAIR PERMIT Location!Address: 2812 NC Highway 801 S-27006
Proposed Facility:. Residential -Repair Propedy Size: 0.950 Acre
ATC**M;,r 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. �aVV i 1j nk A" 5
'System Type: S.T. Manufacturer_ Tank Date ank Size
Pump Tank Size /,,
System Installed By:, j-1 er yr a H _JJOI �4 hail ' E.H. Specialist: Date: �— a
DCHD 11/06 (Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT REPAIR)
NAME C, O �'` µ J J) {'�'HO �P4>UMB
ADDRESS \ S �r� �,,i"��fC SUBDIVISION IS ON NAME
40 9b 01 s � 5 OLA fi �Gf� # �4�-�/ PW d If
DIRECTIONS TO SITE '
DATE SYSTEM INSTALLEDNAMENAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
J /'Y u.. -Gt t
TYPE WATER SUPPLY (.0 W/ SPECIFY PROBLEM OCCURRING S({ W&C t%Azz 4(--(
..e (A j
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. 1193
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 #:
990005681
Billed To:
Mark Philpott
Reference Name:
REPAIR PERMIT
Proposed Facility:
Residential -Repair
Tax PINI H #: 5789 -20 -4814 -REPAIR
Subdivision Info:
Location/AddreSS',,2812 NC Highway 801 S-27006
Property' Size -.f 0.950 Acre
AT'l lr�ee his P�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 IP/ AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat
o� the intended use change.
Residential Specifications: # Bedrooms `�' # Bathrooms 1Z # People Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size. Type of Water Supply: e6ountylcity Well ❑ ommunity Well
System Specifications: Design Wastewater Flow (GPD)" T UG Tank SizeLjO AL. Pump Tank GAL.
��
Trench Width 3Z Max. Max. Trench Depth 3� Rock Depth {C— Linear.Ft.
As stated in 15A NC ,
Site Modifications/Conditions/Other: , G p* gn 1�
'ec# v3'st r0s may alio ho
Contact the Davie County Environmental Health Section for final inspection of
8:30 - 9:30a.m. on the day of installation. Telephone # (336)753-
I �q
,,o
IQ
Environmental Health Specialist
DCHD 11/06 (Revised)
i
system between
5
a
6`
Davie County Environmental Health
P.O. Box 848/210 Hospital Street
• Mocksville, NC 27028
(336)753-6780 / Fax (336)753-1680
WELL PERMIT
Account #: 990005681 Tax PIN/EH #: 5789 -20 -4814 -Well Abandonment
Billed To: Mark Philpott Subdivision Info:
Address: 2812 NC HWY 801 S. Location/Address: 2812 NC Highway 801 S-27006
City: Advance , . Property Size: 0.950 Acre
Reference Name:
Proposed Facility: Well Abandonment
Actions of the employees of the Davie County EH Section shall in no way be taken as a guarantee that this
well will produce water of any particular quantity or quality or for any amount of time. This permit is valid
for a period of 5 years from the date of issuance. This permit maybe revoked if it is determined that there
has been a material change in any fact/circumstances upon which this permit was issued.
Permit Type: New ❑ Repair ❑ Abandonment
W.P. 7-08
Proposed Well Location Diagram
Certificate of Completion Diagram
•
Remove pump, piping and wiring from well
•
Excavate down to 3 feet below ground surface
•
Excavation should be at least 1 foot around the
casing
•
Remove casing down to excavation level
•
Chlorinate well with 70% hypochlorite solution
•
Fill well with concrete to excavation level and 1
foot around the casing
•
Cover with soil
•
Owner/Agent, must call and schedule
abandonment
Comments:
Driller:.
Certification #:
Grout Inspected:
Well Head Inspected:
GPS Coordinates:
EHS: Date:
EHS: Date:
W.P. 7-08