205 McKnight Rd , - �� t � ' " 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 #: 990005936 � T�x PI��EH#: C600000088A
�ifl�d 70: Ashlyn Montgomery Subdivisiort 1nfo:
Refer�Eace Rtan�e: REPAIR PERMIT - - `'� Lac�#ionlAdtlr.�ss:� 205 McKnightRoad-27006
Propas�d Faciiity: Residential Repair . • : . Pto��r�y&ize'����.13.20 Acres . :�: .� '
ATC N�amb�r: 5972 �
**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:_�S.T.1Vlanufacturer l �n Tank Date / Tank Size /
Pump Tank Size � Bedrooms�_
System Installed By:I�L�_�,(/ �l.L��Q� Inspector#: Date: ?D�Z
GPS Coordinate: �
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Environmental Health Specialist: Date:_���21r�b12
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DCHD 11/06(Revised)
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DAVIE COUNTY ENVIRONMENTAL HEALTH
- ' � � P.O.Box 848/210 Hospital Street
' � ' Mocksville, NC 27028
(336)753-6780/Fax#(336)753-1680 .
AU'�HORIZATION FOR WASTEWATER SYSTEM CONSTRUCTIOIY •
Acc�u�t #: 990005936 . '��x PI�€iEH#: C600000088A
Biil�;d Ta: Ashlyn Montgomery � Subdi�fisiort i�fo:
Refer�E�ce Name: REPAIR PERMIT , . '� - LocaiioniAddr�ss: 205 McKnight Road-27006� .; : -
Prop����ci Fa�i€ity: Residential Repair � � � ` '` ��ope�i�`���� �e���ir ❑Expansion , �
**N�Q T�,�.,*,*Thi �horization to Construct(ATC)MUST BE ISSUED:by the Davie County Environmental '
�T�e'a7�"S"ec�ion pr"io�to.issuance of any building pernut(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 FNE YEARS. This ATC is subject to revocation if site plans,plat
or the intended use change.
Residential Specitications: #Bedrooms�#Bathrooms #People�Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats �
Square Footage(or Dimensions ofFacility) �
Lot Size •ZdG,I, Type of Water Supply: �County/City ❑Well OCommunity Well
System Specifications: Design Wastewater Flow(GPD)���Tank Size�' AL.Pump Tank GAL.
�
� Trench Width� Max. Trench Depth�(,� Rock Depth� Linear Ft.�
Site Modifications/Conditions/Other: �D �LkU���
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 11/06(Revised) '
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' � . DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST
APPLICATION IP/ATC OSWW REPAIR `/O�Z��
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�Name (� Telephone Number — Z�
Address � I/ 06
Mailing Address (if different from above) ` .
Email Address: � . 3.
Subdivision Name Lot# � m i � ts
Directions 0 - � / SS /U V�
Zi ro �r-� �e-�-��
Date System Installed %�� 02�°� - Name System Installed Under S
Type Facility '��f Number Bedrooms_� Number People Served �
Type Water Supply � Specific Problem Occurring �
r � � /
Da e Requested �- /5— Z� 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
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