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1390 Cornatzer 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 . 1 Account #: 990002161 Tax'PIWEH#: H700000017 Billed To: Comatzer Baptist Church Subdivision Info a70�S Reference Name: REPAIR PERMIT LocalioniAddress:'.1390 Cornatzer Rd-2072$ _ Proposed Facility: Church Repair Property Size: " 1.84 Ac ATC Number: 6007 **NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC has been installed in compliance with Article 1 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. •,f System Type:!-D l Nub S.T.Manufacturer� \ `�G Tank Date Tank Size � Pump Tank Size' / Bedrooms System Installed By:1/.Q l( jVtttoyb.SOK Installer#: Date: GPS Coordinate: 1 ��11AI � I t = �� r►tel R�C" r�f)L ( /(A. Environmental Health Specialist: Date: it 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 #: 990002161 Tex PINIEH#: H700000017 Billed To: Comatzer Baptist Church Subdivision Info: Reference Name: REPAIR PERMIT Location/Address:'.1390 Comatzer Rd-207028 Proposed Facility: Church Repair Property Size:;'%. 1.84 Ac Site Type: .❑New PRepair ❑Expansion ATC Number: 6007 **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 .Z #People Basement❑Basement plumbingG Non-Residential Specifications: Facility Type # People 4 Seats Square Footage(or Dimensions of Facility) Lot Size - Type of Water Supply: OCounty/City RWell DCommunity Well System Specifications: Design Wastewater Flow (GPD) Tank Size _Y AL.Pump Tank_/1" GAL. Trench Width ( Max.,Trench Depth` Rock Depth 10Linear Ft. C95`'l0 Site Modifications/Conditions/Other: Contact the Davie Coun Environmental HeAlth Section for final inspection of this system between 8:30—9:3 la.m.on the day o ins a s ►op. e e 751-8760. S �sL ra � Elu r a Environmental Health Specialist Date: 20[z DCHD 11/06 (wised) DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:. Issued in Compliance With G.S. of North Carolina Chapter 130 Article 13c Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name i����i�y,i .% ��/'�/, f '�G' Date %d' �'`t© 3606 Location Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home Business Speculation No. Bedrooms No. Baths' No. in Family _ Garbage Disposal YES p NO p--- Specifications or System. 7 Auto Dish Washer YES NO fl /�L, �� Auto Wash Machine YES NO'p //" Type Water Supply 7ins �*This permit Void if sewage system describ d below is ned_witf i 36 months from date of issue. Z 7A I �fU�t l Improvements permit b '��// ' *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by _ r Certificate of Completion Date 6 5Y— *The signing of this certificate shall indicate that the system descri above has be n installed in compliance with the standards set forth in the above regulation, but shall in NO way bet ken as a guaran ee that the system will function satisfactorily for any given period of time. DAVIE COUNTY HEALTH DEPARTMENT _` IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:,Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name Date 1 Vii^: .first�J Location Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _ .. Business Speculation No. Bedrooms No. Baths `2 No. in Family Garbage Disposal YES ❑ NO ❑-- Specifications for Systerrl.- t Auto Dish Washer YES q NO ❑ jJ� /��;%,f,:;�- J C' %�c•ru- Auto Wash Machine YES © NO ❑ Type Water Supply' *This permit Void if sewage system describdd below is not+instal led_witl�A 36 months from date of issue. i J, , _ Improvements permit by *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by 1 l 7-��;s/ Certificate of Completion y Date 'The signing of this certificate shall indicate that the system descri ec,/above has be n installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guaran ee that the system will function satisfactorily for any given period of time. t--a rPennittee'sf'7 n DA IE'COUNTY HEALTH DEPARTMENT S�1 Name: tr/I/+� �' r ', i<< / �. z -Environmental Health Section PROPERTY INFORMATION / P.O. Box 848 Direcdoris't property: 1r�4 ,,, ,r� r, ,r ���r ' s Mocksville,NC 27028 Subdivision Name: Phone#:336-751-8760 ,tel' X's C/-�//d �> Section: Lot: AUTHORIZATION FOR WASTEWATER Office SYSTEM CONSTRUCTION Tax PIN:# - - AUTHORIZATION NO: A Road Name: Zip: **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits.This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ` / �_,+,� rr �, Y .•- ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION .` , 'J>1/.. ,` ✓ - i'� -� IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH§fECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYAJ/W/ #PEOPLE #P EOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZEGAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH—'`--c LINEAR F I�C�� OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: j IMPROVEMENT PERMIT LAYOUT **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. i OPERATION PERMIT SYSTEM INSTALLED BY: VY� AUTHORIZATION OPERATION PERMIT BY: DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYS DESCRIBED ABOVE 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. DCHD 02102(Revised) r • � � Go v D�• DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION (� APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) c� NAME r 4'Z-t4 G4-' PHONE NUMBER ( l$ `_/ ZQ ADDRESS___ /3 '/ a- ✓ nt,f .r_09_ SUBDIVISION NAME M-o c. 6f. S d .... /v c LOT # DIRECTIONS TO SITE DATE SYSTEM INSTALLED (rte (S NAME SYSTEM INSTALLED UNDER TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING L 4-1 A.,,v Av� `V DATE REQUESTED INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowledge,and that I understand 1 am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev.1193