781 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
Account #: 990005720 Tax PIN/EH#: 5758-77-8485
Billed To: Sallie Ava Barney Subdivision Info:
Reference Name: REPAIR PERMIT Location/Address: 781 Cornatzer Rd-27028
Proposed Facility: Residential Repair Property Size: .75 Acre
ATC Number: 5801
**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: S.T.Manufacturer Tank Date Tank Size
Pump Tank Size
System Installed By:� eta E.H.Specialist: N#te:
GPS Coordinate:
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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
REPAIR OPERATION PERMIT
Account #: 990005720 Tax PIN/EH#: 5758-77-8485
Billed To: Sallie Ava Bamey Subdivision Info: ,
Reference Name: REPAIR PERMIT Location/Address: 781 Comatzer Rd-27028
Proposed Facility: Residential Repair Property Size: .75 Acre
ATC Number: 5801
**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.
tSystem Type: S.T.Manufacturer Tank Date Tank Size /
Pump Tank Size
System Installed By: Q E.H.Specialist: 6#te: L
GPS Coordinate:
C3�
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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
REPAIR IMPROVEMENT PERMIT
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990005720 Tax PIN/EH#: 5758-77-8485
Billed To: Sallie Ava Barney Subdivision Info: ,
Reference Name: REPAIR PERMIT Location/Address: 781 Comatzer Rd-27028
Proposed Facility: Residential Repair Property Size: .75 Acre
ATC Number: 5801
**NOTE**This IP/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 IP/AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat
otr the intended use change.
Residential Specifications: #Bedrooms oL #Bathrooms #People Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size QL Type of Water Supply: ❑County/City JWell ❑Community Well
System Specifications: Design Wastewater Flow(GPD) LIO Tank Size GAL.Pump Tank GAL.
Trench Width
�r Max.Trench 1)epthe Rock pthf Linear Ft. 0`2S�D
Site Modifications/Conditions/Other: �PCO/7
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30—9:30a.m.on the allation. Telephone#(336)753-6780.
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Environmental Health Specialist Date: j 2011
DCHD 11/06(Revised)
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http://maps.co.davie.nc.us/GoMaps/map/mapframe.cfm?CFID=4129&CFTOKEN=616408... 7/13/2011
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 Treat nt and Disposal Rules (10 NCAC 10A .193 -.19 ) 1,� Permit Number
Name �' Date ✓ ,,' 3837
i
Location ,,�
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Subdivision Name Lot No. Sec.or Block No.
Lot Size HouseMobile Home_ Business Speculation
No. Bedrooms 3—No. Baths No. in Family
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑
Auto Wash Machine YES ❑ NO C] �� 44 /�
Type Water Supply _—
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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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
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Certificate of Completion Date
"The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation,but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
DAVIE COUNTY HEALTH DEPARTMENT36
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION v/
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
p � �Q�
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit umber
Name Date
3837
Location Location
.j
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 ❑ NO ❑— Specifications for System:
Auto Dish Washer YES NO ❑ _
Auto Wash Machine YES (t NO �❑ '—
i .Type Water Supply
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*This permit Void if sewage system described below is not installed within 36 months from date of issue.
i
t Improvements permit by fx
*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
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Certificate of Completion Date
'The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
'� satisfactorily for any given period of time.
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION v i.
NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c �U
;," Sewage Treatment and Disposal Rules.(10 NCAC 10A .1934-.1968) - Permit Number
17
Name /(%
Date �- /~ - 'tt
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 E) NO p Specifications for System:
Auto Dish Washer YES p NO 0
Auto Wash Machine YES p NO -p - -
Type ,Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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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
N /
Certificate of Completion Date
{The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.