2203 Milling Rd � f `,' , . DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
REPAIR OPERATION PERMIT
,�ccount #: 990005638 '��x�lh€.��H#: 5759-87-6542-Repair
�ifl�s�Tc�: Charles Rapp Su�di�ri�iar� Ir�fz�:
F�efer�E�ce P����e:: REPAIR PERMIT :' : LocationiA��r�s�: 2203 Milling Road-27028 - '
f'ropc�s��c9 F��;iiity: Residential Repair � �cc���r�y S�i7�: 0:790 Acres
����1��`Th�is��ance 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. �
. $ystem Type: S.T.Manufacturer � f Tank Date� Tank Size�
Pump Tank Size
System Installed By: E.H.Specialist: C/V � WI�Date: �
GPS Coordinate:
300 G� �- �,W�.w�r ,
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DCHD 11/06(Revised)
. �
�° DAVIE COUNTY ENVIRONMENTAL HEALTH
, P.O.Box 848/210 Hospital Street �
� ' Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRLJCTION �
Acct���t #: 990005638 "��x�1�f.�EH#: 5759-87-6542-Repair
�illc,d 7�: Charles Rapp Suk�di�i4ian ln�c�:
Refer�r�ce Na���: REPAIR PERMIT LocaiioniAd�r�Ss: 2203 Milling Road-27028
ProposQc9 F;�cility: Residential Repair Pro��r�y Six.�: 0.790 Acres
Site Type: ❑New �rIZepair ❑Expansion
a�*� E��r� 5737
�� 'I'his 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 Specitications: #Bedrooms�#Bathrooms #People Basement❑ Basement plumbing��
Non-Residential Specifications: Facility Type #People #Seats •
Square Footage(or Dimensions of Facility)� '
Lot Size. •� l.,C Type of Water Supply: p�County/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow(GPDk•f� Tank Sizd�� L.Pump Tank�/H GAL.
.0 - `q � ,�(� c� L
6'
Trench Width� Max.Trench Depth� Rock Dep�h�/� Linear Ft.�� `�']" v
Site Modifications/Conditions/Other: � `
Contact the Davie County Environmental He�lth Section for final inspection of this system between.
8:30—9:30a.m.on the da of insfallation. Tele hone#(336 751-8760.
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� 1 Environmental Health Specialist � Date:
DCHD 11/06(Revised) �
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� � ' DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME PHONE NUMBER
ADDRESS - � SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED_���J�Z�,�_INFORMATION TAKEN BY
. �
This is to certify that the information provided is correct to the best of my knowledge,and that I understand I am rasponsible for all charges incurred from thie application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Flev.1/93