727 Fork Bixby RdDAVIE COUNTY ENVIRONMENTAL HEALTH '
• P.O. Box 848/210 Hospital Street
Mocksville, NC 27028 D`
(336)753-6780 / Fax # (336)753-1680 D
REPAIR OPERATION PERMIT
Account #: 990005937
Billed To: Glenda & Jeff Miller .
Reference Narne: EXPANSION
Proposed Facility: Residential Expansion
ATO Number: 5975
Tax PIN/EH #: 1700000093
Subdivision Info
Location/Address: 727 Fork Bixby Road -27006
Property SizO,:- ; 2.99 Ac
**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: JQMi t- (�aryr{J Installer#: Date: p/
Environmental Health Specialist:
DCHD 11/06 (Revised)
`Date:
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
` (3)6)753-6780 / Fax # (336)753-1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990005937
Billed To: Glenda & Jeff Miller
}deference Name: EXPANSION
Proposed facility: Residential Expansion
Tax PIN.,'EH #: 1700000093
Subdivision Info:
LocationiAddress: 727 Fork Bixby Road -27006
InropAp,§W: ate Repair (Expansion
*�* ** �'hi �,�horization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental
ATHeaItt eec ibn prriior 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 chance.
Residential Specifications: #Bedrooms Y # Bathrooms?_ # People 5- Basement❑ Basement plumbing
Non -Residential Specifications: Facility Type # People # Seats_
Square Footage(or Dimensions of Facility)
Lot Sized 9a Type of Water Supply: ®County/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow (GPD) 8V Tank Size t9;(6 OAL. Pump Tank / GAL.
Trench Width 3(p,` Max. Trench Depth t' Rock Depth_ Linear Ft. r�Gr "c�5"/0
Site Modifications/Conditions/Other: IZedl�.(,tYopt
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.
0\�Xxsl�
Environmental Health Specialist
DCHD 11/06 (Revised)
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08/28/2012 13:05
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Davie County Health Department
Environmental Health Section
P.O. Box 848
210 Hospital Street
Cornier 4 : 09-40-06
®�2 Mocksville, NC 27028
•
l ON -BYTE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
NO. 512 1702
PabG- 2.0 S
Fax: (336)-753.1680
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Name. Qoto 4►' --rc-FF Ai! %lL-/L PbDasNmnber 'l3 T �� �' `J� dame)
Mdhg Addrras: %Z7 'Ol rAll to. (Worst)
AeVAWCf TIJ C- EnO Address:
Detpiled Directions To Site- 70G, AA -1 )!�;M A I x.Q V /Qo • �Ie
f,-Ovs� oN LGA ''1060O0olq
ProF M Address'
Plan FDI In The FoRawiag IMormation About/ The EaY MING Facility:
Naas System Installed Limier: Type Of Fad" t/5 & �i Oz
Date System Installed (MaathlAate/Year):2 Z Rto Number Of Bedrooms: Number 4f Pcapk:
Is the Facility Currently Vacant? Yes (!o % If Yes, For Haw Lang?
Any Knowe Pmblems? Yes & If Yes, Explain:
Pieaae PS In The Fdbwbe Info" wtioi Abaft The 1 N.1sW Facility:
Typer Of aetlity: �Uwi u4 & o o m Number C f Bed =L_# % _Number of People
Pool
Requ
ForEnvimolimcow Health Offtce Use Only
Approve Disapproved
(exftM or limited) that the on-site wastewater system will function properly for any given period of time.
ftmo r Cas)f Check , 4dnq Order #
Pgld
By;
Aecoum M Invoice : L�
0) PI&X& Notes r jfuRA,1"e, Qkpvt-r �.v)# /%1,0Std&& 660Aeo.OK
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