278 La Quinta Drive Lot 122DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680
REPAIR OPERATION PERMIT
Account #: 990001067 Tax PIN/EH #: G704OA0071
Billed To: Steven Mitchern Subdivision Info: WAV0,I)CY
Address: P.O. Box 31 Location/Address: 278 La Quinta Dr. -27006
City: Advance Property Size: 0.3500 Acres
Reference Name: REPAIR PERMIT
Proposed Facility: Residential Repair
-ATe,: Vp6-
**NOTE** I he issuance o this Operation Permit shall indicate the system described on the ATC has been installed
in compliance with Article I I 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 Ty e: S.T. ManufactureLd ank Date //,/If/ Tank Size I -019b
Pump Tank Size Bedrooms
System Installed By: MM" �Ibtek installer#: Date:
GPS Coordinate:
Ck)_
Environmental Health Specialist:
DCHD 11 /06 (Revised)
Date: ( kwo I
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/2 10 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (33 )6)753-1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990001067 Tax PINIEH #: G704OA0071
Billed To., Steven Mitchem Subdivision Info: La Quinta Lot# 122
Reference Name: REPAIR PERMIT LocationiAddress:" 2786 La Quinta Dr. -27006
Proposed Fqclllt Residential Repair PropA�P&.F: 0648190&8� DExpansion
hon'zation to Construct (ATC) MUST BE ISSUED by the Davie County Environmental
AT e",
ea ec ion pr r to.issuance of any building permit(s)" (in compliance with Article, I I of G.S. Chapter 130A
Wastewater Systems, Section.1900 Sewage Treatment and Disposal Systems). TEIS 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 chan2e.
Residential Specifications: # Bedrooms —3 4 Bathrooms 2 4 People 6- BasementO Basement plumbingO
Non -Residential Specifications: Facility Type # People #Seats
Square Footage(or Dimensions of Facility)
Lot Size Type of Water Supply: XCounty/City DWell ElCommunity Well
System Specifications: Design Wastewater Flow (GPD) _2yj�Q Tank Size GAL.PumpTank ---GAL.
y f
Trench Width $�L max. Trench Depth RockDepth_,�g Linear Ft. g9c-'�Q
Site Modifications/Conditions/Other:
Contact the Davie County Environmental Heilth Section for final inspection of this system between
8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760.
Environmental Health Speci
DCHD 11/06 (Revised)
Date:5V3�6/
. / f
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/2 10 Hospital Street
Mocksville, NC 27028
(3')6)753-6780 / Fax # (3)6)75' )-1 680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990001067 Tax PIN ','EH #. G704OA0071
Billed To: Steven Mitchem Subdivision Info, La Quinta Lot# 122
Reference Name: REPAIR PERMIT LocalioniAdcItess: 2786 La Quinta Dr. -27006
PrOPA , i�
Proposed Facility: Residential Repair jq..b�: 06.8,go$A&8� ElExpansion
e AT* *f Whor�ization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental
t
e fon i o issuance of any building permit(s) (in compliance with Article I I of G.S. Chapter I 30A
Wastewater Systems, Section. 1900 Sewage Treatment Q 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_J_ # Bathrooms 4PeopleS- BasementO Basement plumbing 0
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size . S5-cl(- Type of Water Supply: DCounty/City OWell DCommunity Well
System Specifications: Design Wastewater Flow (GPD) �3�TankSizejj��h�AL. Pump Tank /-' GAL.
A
Trench Width Max. Trench Depth�� Rock Depth PA Linear Ft. d
Site Modifications/Conditions/Other: (e)' Qne&2S (00'
Contact the Davie County Environmental HeAlth Section for final inspection of this system between
8:30 - 9:30a.m. on the day of installation. Telephon # (336)151-8760.
Environmental Health Speci
DCHD 11/06 (Revised)
-L
K&O
Date: "�-A?Slgol'z
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 #: 990001067
Billed To: Steven Mitchern
Reference Narne: REPAIR PERMIT
Proposed Facility: Residential Repair
Tax'PINIEH #: G704OA0071
Subdivision Info, La Quinta Lot # 122
786 La Quinta Dr. -27006
Locgllon!Addre!�S� �2
Property Size,." z 0.3500 Acres
ATC Number: 5935
**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. Manufacturer Tank Date Tank Size
Pump Tank Size Bedrooms -
System Installed By: Installer#: —Date:
GPS Coordinate:
Environmental Health Specialist: Date:
DCHD 11/06 (Revised)
#Jltlo 'Alld -41111d AJ.NV,(M1'4
DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST
APPLICATION IP/ATC OSWW REPAIR 77
Name - �=Q� Lle /i Ilk J40 o Telephone Number
Address 271� bw.
Mailing Address (if diffe;ent from above)
Email Address:
Subdivision Name A X/ P, 46 Lot #
Directions
Cn -1040A 00-71
Date System Installed Name System Installed Under
TypeFacility Number Bedrooms Number People Served
Iva
Type Water Supply Specific Problem Occurring aLILN�v e -A..,
67V
Date Requested 54-qj1Z-, Raj _ Info Taken By
THIS IS TO CERTIFY'fHA'T' THE INFORM ATIbN 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 1/
WMOS-i
GoMAPS - Davie County NC Public Access
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* * *WARNING: THIS IS NOT A SURVEY! * * *
This map is prepared for the inventory of real property found within this jurisdiction, and is,compiled from recorded
deeds, plats, and other public records and data. Users of this map are hereby notified that the aforementioned public
primary information sources should be consulted for verification of the information contained on this map. The
County and mapping company assume no legal responsibility for the information contained on this map.
F-1 WATERSHED—STRUCTURES
WATER—BODIES
E-1 COUNTY—BOUNDARY
STREETS
RAILROAD—CENTERLINE
PARCELS
CITY—LIMITS
F-1
BERMUDA RUN
F-1
COOLEEIAEE
F-1
DAVIE COUNTY
r-1
MOCKSVILLE
nccounties
DAVIE
<all other values>
Tuesday, May 8 2012