547 Pineville Rd (2) , . DAVIE COUNTY ENVIRONMENTAL HEALTH
� ' '� P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax# (336)753-1680
REPAIR OPERATION PERMIT
�ccou�t �: 990005841 '��x F���i�H#: B500000032
Bilic,� T�: Patricia Genovese ;��7di�ri,ior1 lr��c7:
Re:fer�r�ce P��€���: REPAIR PERMIT Lac�tioniAd�r�ss: 547 Pineville Road-27028
€�ropo���9 F��:i€i�y: Residential Repair �rop�r�y S�iz�: 8:83 Acres
a,T'C Nu�tb�3': 5899
**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_f� Tank Date � Tank Size �
Pump Tank Size � / Bedrooms �
System Installed By:�(�Ct��1K� I�(JlV��O(�l Inspector#: Date:�/�Z
GPS Coordinate:
�
��
�`� �� ►�
�
�
� .
t�
�
Environmental Health Specialist: Date:_��/�joz .
�
DCHD 11/06(Revised)
�NUv �c� gU �
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
Accr�u�t �: 990005841 "��x PINi�H#: B500000032
Biflt,i� TQ: Patricia Genovese 5u���i��i�3QT1 If3��7;
f�e��e�-�E�c� �ta€���: REPAIR PERMIT Lac�lioniAd�r�ss: 547 Pineville Road-27028
f�ropc���;i9 Fa�:i€ity: Residential Repair �'ro��ri,y �ix.�: 8.83 Acres '
Site Type:Repair�Q Expansion()
N�TC Nu�tber: 5899
**NOTE** This IP/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
or the intended use change. '
Residential Specifications: #Bedrooms�#Bathrooms #People 1 Basement0 Basement plumbing0
Non-Residential Specilications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility) .
Lot Size ��3 G�� Type of Water Supply: OCounty/City �Well ❑Community Well
System Specifications:' Design Wastewater Flow(GPD) ��Tank Size(-_�J AL.Pump Tank l GAL.
Trench Width 3(��� Max. Trench Depth�_ Rock Depth� Linear Ft.�o��a�0
Site Modifications/Conditions/Other: � �(��1C,710n
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30—9:30a.m.on the da of installation. Tele hone# 336 753-6780.
� �'���eXis � �.
-b �e� i� i� ha �u��
J� i f�i� ; ,'��`r ��w �oci�
��� ,J '� ' ` sr T ►'b�
3 �OrPe �� � � � ��'
� ir�s��►� a«>`as�� ���6h
� �a�� �
,
,
,
,
� �x�S��
. �
� � ��
� ��
DCHD 11/06(Revised)
�
� ' • • � DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME (�IC(GZ, �i{�DUP�S�i PHONE NUMBER �G��"J ���
ADDRESS_ ��l'7 1���n�U!!1� � ��61;{Ci�Ul/I� SUBDIVISION NAME �/ �c9�
LOT #
DIRECTIONS TO SITE . B�b���00 3Z.
g.�7J� :
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER_y�r/�� 1�U`�/I ��OC��G
TYPE FACILITY 6�5� NUMBER BEDROOMS � NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING��n`CS �C���i[ � �
� �o �
DATE REQUESTED INFORMATION TAKEN BY
This is to certify that the information provided is corcect to the best of my knowledge,and that I undersWnd I am responsible for all charpes incurced from this appiication.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
R.,,.,/93
� '