640 Cedar Grove Church Rd DAVIE COUNTY ENVIRONMENTAL HEALTH N
P.O.Box 848/210 Hospital Street J\�
Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680 ✓
REPAIR OPERATION PERMIT
Account #: 990003991 Tax PIN!EH#: K700000025
Billed To: John Ellis Subdivision:Info*
Reference Name: REPAIR PERMIT . LocationiAddrass .'640 Cedar Grove Church Road-2702
Proposed Facility: Residentia Repair Property Size:. -46.73 Acres
ATC Number: . 5880
**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.ManufacturerTank Date Tank Size
Pump Tank Size
System Installed By: AA E.H.Specialist: PAd" *t4teZ1ZD�z
GPS Coordinate:
01
1b
2'
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
AUT=HORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990003991 Tax PIN/EH#: K700000025
Billed To: John Ellis Subdivision Info:
Reference Name: REPAIR PERMIT Location/Address!-.,'640 Cedar Grove Church Road-2702
Proposed Facility: Residentia Repair Prope�lrixe: N 73res
i e ype: 0 ew epair ❑Expansion
A-C� 1 �'�r'i'hiA%iorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental
Health Section prior to.issuance of any building pen-nit(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 3 #Bathrooms #People BasementO Basement plumbingO
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size L_ Type of Water Supply: ❑County/City 54Well ❑Community Well
System Specifications: Design Wastewater Flow(GPD),;2nJor)_Tank SizeQItk GAL.Pump Tank GAL.
Trench Width Max. Trench Depth ` Rock epth� Linear Ft.�( j �a
Site Modifications/Conditions/Other:
Contact the Davie.County Environmental Hefilth Section for final inspection of this system between
8:30—9:30a.m.on the day of installation. Telephone#(336)751-8760.'
r o
Environmental Health Specialist tv Date:.4
DCHD 11/06(Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
f�
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME ��O`�G'l C��l/S PHONE NUMBER
ADDRESS `�� PL�r ` � SUBDIVISION NAME
LOT#
DIRECTIONS TO SITE
// n
DATE SYSTEM INSTALLED �tS I NAME SYSTEM INSTALLED UNDER
TYPE FACILITY Q.. NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY L a jjj_ ___-_ SPECIFY PROBLEM OCCURRING
DATE REQUESTEINFORMATION TAKEN BY
This is to certify 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.1193