354 Livengood Rd �
DAVIE COUNTY ENVIRONMENTAL HEALTH
' �i' ' P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
REPAIR OPERATION PERMIT
Acct�u�t �: 990005892 � � '��x PINiEN#: 1800000014
�illcd TQ: Dennis Livengood ' Sufa�ivisior�.�nf�:• , . �. ':,„:
Refer�r�ce Name: REPAIR PERMIT ' Locaiion)Adii��ss:".354 Liven ood Road-27006 °°
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Pro�ased Faci[ify: Residental Repair � ° P�o�er�y�Si��:� ��1:85 Acres .
tOTC Numb�r: 5943 . .- ...
**NOTE**The issuance ofthis 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: .� S.T.Manufacturer� �5�'v! Tank Date � Tank Size !
Pump Tank Size „i- Bedrooms 3�
System Installed By: �2Q►�(� �,((,�(�'b��S(�Y� Installer#: Date:
GPS Coordinate:
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Environmental Health S ecialist: "V�� Date: b/
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DCHD 11/06(Revised) �NU.#- ���
DAVIE COUNTY ENVIRONMENT.�L HEALTH
� P.O.Box 848/210 Hospital Street
Mocksville, NC 27028
. �� , (336)753-6780/Fax#(336)753-1680 .
AUT,HORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION �
Acco�a�t �: 990005892 ' '��x PI��EH�: 1800000014
8ille:d 7Q: Dennis Livengood Suf�di�risiari I�f�: . �
R�Fer�r�ce Nan��: REPAIR PERMIT . Locatio�►iAddress:'.354 Livengood Road-27006
Prnpas�d Facifity: Residental Repair � � p��y�����'�����}`��p��air ❑Expansion
��**N�,T *�*Thi��i�thorization to Construct(ATC)MUS.T BE ISSUED by the Davie County Environmental
�e'aTfh�ec�ion prior to.issuance of any building permit(s),�(in coinpliance with Article 11 of G.S.Chapter 130A
Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). TAIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FNE YEARS. This ATC is subject to revocation if site plans,plat
or the intended use change.
Residential Specifications: #Bedrooms�#Bathrooms #People Basement0 Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats �
Square Footage(or Dimensions ofFaciliry) �
Lot Size ����� Type of Water Supply: ❑County/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow(GPD) ��Tank Size�'cS�L.Pump Tank �'� GAL.
�
Trench Width�c�� Max. Trench Depth �C�� Rock�Depth �/� Linear Ft. 3O6 a��`o
Site Modifications/Conditions/Other: : �a11��jS�
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Contact the Davie County Environmental He�lth Section for final inspection of this system between
8:30—.9:30a.m.on the da of installation. Tele hone# 336 751-8760.
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Environmental Health Specialist • Date: <� ��'
DCHD 1]/06(Revised)
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' - DAV'IE COUNTY HE�LT�I�EPARTMENT
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; � , (Septic Tank) Improvements Permit and�Certificate of Completion ..
(Ground Absorption Sewage Disposal System - G.S. Chapter 130-Article 13C)
OWNER OR CONTRACTOR _ •:� : , ,, � ; . . � :�;, :J'�r DATE . : •�. PERMIT ;:_:�;�
s..�., _� .�..�..� �... ... . - N� 5 01
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LOCATI ON � , �-� �, _ .., • ti �f .. , . } �R,,;,, {'�} R -... �,�. ;1 ' � ,.,�.,�; �t� � '
-- S.R. N0.
SUBDIVISION NAME LOT N0. SECTION OR BLOCK N0.
HOUSE ❑ MOBILE HOME BUSINESS ❑ -
N0. BEDROOMS 'z N0. BATHROOMS House Trailer �38@-����,,��-A9�,�
Two Bedroom House $00--Gal. 600:,.,S.s�.,_..F-t.
GARB�AGE DISPOSAL UNIT YES ❑ NO ❑ Three Bedroom House 900 Gal. 900 Sq. Ft.
AUTO. DISHWASHER YES ❑ NO ❑ Four Bedroom House 1000 Gal. 1200 Sq. Ft.
AUTO. WASH. MACHINE YES ❑ NO ❑ ' '
SITE SUITABLE ;� ' YES ❑ NO ❑ � �•�►�,,:, .: �i;;�X o �r�,r
SI ZE OF TANK ^�..+''"- � ga l. , ,��,
NITRIFICATION FIELD , �dD sq. ft. •
� �E t,c., �•�a���," �� X C*`+
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. DEPTH OF STONE IN LINESs M � � � 'Y` .�' ��;�j�'�' �`{
WATER SUPPLY: Individual: Q Public . ❑ `
� IMPROVEMENTS PERMIT BY ,�=''► ;"� ` � �'`^� INSTALLED BY �,p.,�u�,, '.�,'�'. (`„p•
' CERTIFICATE OF COMPLETI02�1 By ,� Date�" � �' 7�
(8/16/73) *Construction must co ply with all other applicable State and local regulations ,
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