3099 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
Aconunt M 990005976
Billed To: Steve Hege
Reference Nance: REPAIR PERMIT
Proposed Facility: Residential Repair
Tax PIN.,EH #: 1800000054
Subdivision -info:
LoccflioniAddress: 3099 NC Highway 801 S-27006 .
Pfoperty Size: 14 Acres
ATC Number: 5999
**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: C'`SManufacturer_ 'i S i Tank Dade / Tank Size
Pump Tank Size / Bedrooms 2
System Installed By: 0 Installer#: Date:111� l I Z
GPS Coordinate: I
DCHD 11/06 (Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH
r P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
: (336)753-6780 / Fax # (336)753-1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990005976
Tax PIRIEH #: 1800000054
Bilied To: Steve Hege
Subdivision Info:
Reference Narne: REPAIR PERMIT
LocationfAddress: 3099 NC Highway 801 S-27006
Proposed Facility: Residential Repair
Property Size: 14 Acres
Site Type: ❑New Repair ❑Expansion
ATC Number: 5999 :
**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
4 People BasementO Basement plumbingO
Non -Residential Specifications: Facility Type
# People # Seats
Lot Size �' G
System Specifications:
Site Modifications/Conditi
Square Footage(or Dimensions of Facility)
Type of Water Supply: ❑County/City OWell OCommunity Well
Design Wastewater Flow (GPD) ��Tank Size fC AL. Pump Tank GAL.
Trench Width S a`' Max., Trench Depth3ek Rock Depth Linear Ft.an:0/0
r_
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 Specialist
DCHD 11/06 (Revised)
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I
DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST
APPLICATION IP/ATC OSWW REPAIR e'?%Z
Name 0 V 4Telephone Number ` 0-zw
Address q A16 l/ O 0
Mailing Address (if different from above) qW- (o U
Email Address: wolD S�@ ijod d . l 4,
Subdivision Name gG4do! Lot #
Directions AE. WV oAI `Bili/ 01 & ON Od 1I
!�l9'
Date System Installe 16 Q I Name System Installed Under
Type Facility U, S'. Number Bedrooms o Number People Served
Type Water Supply Specific Problem Occurring
% QS
Date Requested -I 7i Info Taken By
THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY
KNOWLEDGE, AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED
FROM THIS APPLICATION.
Signature of owner or Authorized Agent
Initial Fee Date REHS
Revisit Charge Date Reason
Revised 2-2011
5Q -7w
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DAVIE COUNTY HEALTH DEPARTMENT 7 W4
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name Date e;
r- - ... .. t ....
Location _
eo
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home __ Business __ Speculation
No. Bedrooms _ No. Baths No. in Family —
Garbage Disposal YES ❑ NO ❑ ~ Specifications for System:
Auto Dish Washer YES ❑ NO ❑
Auto Wash Machine YES ❑ NO ❑ 'rr
Type Water Supply ---
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
1
Improvements permit by
'Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by
c.
i
Certificate of Completion — Date
"The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested By Business Phone
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Iter Repair
b) Privy Conventional -"tether Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home----BGsiness
Industry Other
b) Number of people b.-?
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms Bath Rooms Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 1
7. Number and type of water -using fixtures:
commodes urinal
lavatory
showers
garbage disposal
washing machine
dishwasher sinks
8. a) Type water supply: Public �vate Community
b) Has the water supply system been approved? YesZ— -No-
9. a) Property Dimensions
b) Land area designated to building site
c) Sewage Disposal Contractor 1
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify that the information is correct to the best of my knowl dge.
7r 7 Date �` r a Owner Sigure
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE 1 ITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-62)
A