173 Westridge Road Lot 27* 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 #: 990005965 Tax PINiEH #: E811 OA0006
Billed To: Donna Neeley Subdivision Into: Westridge II Lot # 27
Reference Narne: REPAIR PERMIT LocationiAddress:173 Westridge Rd -27006
Proposed Facility: Residential Repair Property Size: 0.52 Ac
ATC Number: 5990
**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: Lnufacturer \ Tank Date Tank Size -0'0'Pum Tank Size Bedrooms
System Installed By:�A AAI Idler 1,SAA InstallerM Date: atal
GPS Coordinate:
'T Z�
` 52'
Environmental Health Specialist: P I A fA A WA Date:
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 CONSTRUCTION
Account #: 990005965 Tax PIN%EH M E811OA0006
Billed To: Donna Neeley Subdivision Into:: Westridge II Lot # 27
Reference Name: REPAIR PERMIT LocationiAddress:' 173 Westridge Rd -27006
Proposed Facility: Residential Repair Prbperly Size: 0:52 Ac
Site Type: ❑New J6Repair ❑Expansion
ATC Number: 5990
**NOTE** This 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 Specifications: # Bedrooms # Bathrooms 4 People Basement❑ Basement plumbingG
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size Type of Water Supply: I)9County/City ❑Well ll❑Community Well
System Specifications: Design Wastewater Flow (GPD) Tank SizeaLl AL. Pump Tank "GAL.
Trench Width Max. -Trench DeptRock DepthA) Linear Ft.ODII,O
Site Modifications/Conditions/Other:
Contact the Davie County Environmental HeAlth Section for final inspection of this system between
8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760.
r I t e- L► �b etnl�ia
Environmental Health Specialist ' DaterV9 0/
DCHD 11/06 (Revised) I
DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C)
OWNER OR �CONTRACTOR�+ ? -''r a..: DATE l;"�` %� PERMIT
_. � ~` �• N9# 1848
LOCATION x r ; : < <i: ,.,a . w� ,..t
S.R. NO.
SUBDIVISION NAME '-, .'t LOT NO. SECTION OR BLOCK NO.
HOUSE t] MOBILE HOME ❑ BUSINESS
NO. BEDROOMS
NO.
BATHROOMS
-
GARBAGE DISPOSAL UNIT
YES
❑
NO
-
0-
AUTO. DISHWASHER
AUTO.
YES
❑
NO
❑
AUTO. WASH. MACHINE
YES
1�3
NO
❑
SITE SUITABLE
YES
[3,
NO
❑
SIZE OF TANK
gal.
NITRIFICATION FIELD sq. ft...
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ❑ Public yQ
IMPROVEMENTS PERMIT BY
r t
House Trailer
Two Bedroom House
Three Bedroom House
Four Bedroom House
INSTALLED BY
800
Gal.
400
Sq.
Ft.
800
Gal.
600
Sq.
Ft.
900
Gal.
900
Sq.
Ft.
1000
Gal.
1200
Sq.
Ft.
r
CERTIFICATE OF COMPLETION By Date a 7
(8/16/73) *Construction must omply with all otlhr applicable State and local regulations
LOT AREA
• w _ n6
V
DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
HOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Si E;1,/ati�, NAME�,, DATE ISSUEDNA
ADDRESS?,0- j WO!;'
PERMIT NO.
Explanation of charge /-% p,, (�,��,,,-� - 41*' a7 - [,c/v� �IF
J
AMOUNT DUE /S, IN SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.
DAVIE COUNTY HEALTH DEPARTMENT PIZ
P. 0. BOX 57
11OCKSVILLE, N. C. 27028 /V
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME , DATE ISSUED 9''�F 17e
ADDRESS PERMIT NO. O
IW
Explanation of charge
AMOUNT DUE --�`'r SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATBOMENT.
_. �nd r.a,,,,,f
DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQ EST
APPLICATION IP/ATC OSWW REPAIR
Name Telephone Number 1,37
Address
Mailing Address (if different from above)
Email Address:
Subdivision Name Lot #�
Directions
c 4-6; 1-q ,5
Date System Installed Name System Installed Under
Type Facility R- S; (l p b(. V Number Bedrooms_ Number People Served
Type Water Supply Mj Ln; �.i �� Specific Problem Occurring
Date Requested to/Z2//2' 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*W)� Date REHS
Revisit Charge Date Reason
Revised 2-2011
'nlot,<J1 it��I �- (O hal lZ e -all Mrs 1ja-P-IL-i -)a