155 Caravan Ln • 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 #: 990005843 Tax PIN'/EH#; G300000046
Billed To: Elender Johnson Subdivision Info:
Reference Name: REPAIR PERMIT -27028LocationiAddress: 155 Caravan Lane
Proposed Facility: Residential Repair Property Size: 0.49 Acres
ATC Number: 5902
**NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC has been installed
in compliance with Article I 1 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 q
System Installed By5"4y% / 12&yfS Inspector#: Date:
GPS Coordinate:
1
Environmental Health Specialist: Date:
DCHD11/06(Revised) 1 ide �S �bV
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 #: 990005843 Tax PIN,EH#: G300000046
Billed To: Elender Johnson Subdivision Info:
Reference Name: REPAIR PERMIT LocationfAddress:°'155 Caravan Lane-27028
Proposed Facility: Residential Repair Property Size: 0.49 Arres
Site Type: ❑New VjiKepair ❑Expansion
AT* I *,rihiRSorization 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 Z #Bathrooms 4 People BasementO Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats -
Square Footage(or Dimensions of Facility)
Lot Size . qac Type of Water Supply: ®County/City ❑Well OCommunity Well.
System Specifications: Design Wastewater Flow(GPD)gqo Tank Size Z GAL.Pump Tank GAL.
Trench Width Max. Trench Depth % Rock Depth ./ Linear Ft.
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.
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Environmental Health Specialist Date:
DCHD 11/06(Revised)
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• '' DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
9� /r II
NAME E/tJ--)d (-�� c,jhhr>SI5Yv PHONE NUMBERS?56e 4DCc C154ZLl Cc�t
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ADDRESS /y 1:'>J� l >�f'C,n/'�.n !l
_Gt�L _ SUBDIVISION NAME
�( D \ 4-I m t,,&,'at/GI.t,-i Lam LOT # rnJ4 o_(tnm Id
�Q DIRECTIONS TO SITE
Hour,( kx:t-j l q(07..
DATE SYSTEM INSTALLED 1) --NAME SYSTEM INSTALLED UNDER
TYPE FACILITY - � �-NUMBER BEDROOMS Z NUMBER PEOPLE SERVED
,,I t
TYPE WATER SUPPLY LD�� SPECIFY PROBLEM OCCURRING O( 1,(9T Of
DATE REQUESTED INFORMATION TAKEN BYC:�2 �L
This is to mortify that the information provided is correct to the best of my knowledge.and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93