638 Pineville Rd DAVIE COUNTY ENVIRONMENTAL HEALTH
�- P.O.Box 848/210 Hospital Street
. ' Mocksville,NC 27028
' (336)753-6780/Fax#(336)753-1680 .
REPAIR OPERATION PERMIT
Acc�ur�t �: 990005694 "��x�i�€iEN#: 5843-28-1116
Bille;d T�: Cody Sagraves Su�idivi4ior� Inf�: �
Re:fer�r�ce Rl�n��: REPAIR PERMIT LocatianiAd�r�ss: 638 Pineville Road-27028
Propc�s�c9 �'��iiity: Residential Repair F'co�er�y S�iz�: 18.900 Acres
p�T�'�T���The�'��Ssuance 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.Manufacturer��� Tank Date�� Tank Size /"
Pump Tank.Size � ,
.� ��
System Installed By: (� iri � � IXI'" E.H. Specialist:,�(� %• Date: I���
GPS Coordinate:
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DCHD I 1/06(Revised) � �7��
�N(f D aC�
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
Account #: 990005694 T�x �I�:�}-�#: 5843-28-1116
�ill�d 70: Cody Sagraves SuE��i�ri�ior� lr�fo: , '
Re:fer�r�ce P�t���e:: REPAIR PERMIT l.ocaiion�Ad�r�ss:;.'638 Pineville Road-27028
f�ro�c�s�;c9 F��;i€ity: Residential Repair �rr���r�.y �iz�: � ;�18.900 Acres
p,���'�'��his-IP7 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 Dispo'sal Systems). THIS IP/AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat
o�the intended use change. ;,
Residential Specifications: #Bedrooms�#Bathrooms � #People�Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size Type of Water Supply: �1County/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow(GPD)�Tank Size�GAL.Pump Tank�GAL.
t�
Trench Width� Max.Trench J�epth ��O�� Rock Depth� Linear Ft.�����
Site Modifications/Conditions/Other: • ' i� `,''� �'
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.
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L gJrivironmental Health Specialist Date: G
DCHD 1 I/06(Revised)
� , - � DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
� � ' APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) �� ' ��Ob
NAME � PHONE NUMBER �
ADDRESS �Q �� Qi��l�/��Q ��D V//I�UBDIVISION NAME
LOT #_
DIRECTIONS TO SITE �'Yb� �Ol(� I` N
�IO ��v �l�e d L
DATE SYSTEM INSTALLED ` NAME SYSTEM INSTALLED UNDER �G�iG� `� �a!
TYPE FACILITY P� NUMBER BEDROOMS J NUMBER PEOPLE SERVED
TYPE WATER SUPPLY � � �PECIFY PROBLEM OCCURRING �ZG
� �" 4s 3—Z�-
DATE REQUESTED �� �I I INFORMATION TAKEN BYT�./7�
Thie is to certify that the information provided is correct to the best of my knowledge,and that 1 understand I nm responsible(or all charges incurred from thie application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Flsv.t/93 � i /'��
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http://maps.co.davie.nc.us/GoMaps/map/map.cfm?CFID=4129&CFTOKEN=61640881 6/3/2011