185 Frost RdDAVIE 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 #:
990005715
Billed To:
Jake Blackwell
Reference Name:
REPAIR PERMIT
Proposed Facility:
Residential -Repair
Tax PIN: EH #: 5851 -85 -6756 -Repair
Subdivision Info:
LocationiAddress: ,185 Frost Road -27006
Properly Size: -2:29 Acres
A * is IP//6Authorization 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
or the intended use chance. :!
U
Residential Specifications: # Bedrooms2- # Bathrooms # People 2 Basement Basement plumbing
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size Type of Water Supply: ❑County/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow (GPD),2z Tank Size.�AL. Pump Tank GAL.
Trench Width-36"Max. Trench i)epth, Rock Depth��79 Linear Ft.�
Site Modifications/Conditions/Other:
Contact the Davie County Environmental Health Section for final inspection of this system between
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 #: 990005715 Tax PINIEH #: 5851 -85 -6756 -Repair
Billed To: Jake Blackwell
Reference Name: REPAIR PERMIT
Proposed Facility: Residential -Repair
Subdivision info:
LocationiAddress: Frost Road -27006
Property Size: 2.29 Acres
AT ffi�*r*The isu ance 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. ManufactureTank Date Tank Size
Pump Tank Size
I /System Installed By:�' M E.H. Specialist•
GPS Coordinate:
DCHD 11/06 (Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTIONVc
(/ APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) ?
NAME:UC 614616WW PHO E NUMBER
c4 -70k
ADDRESS 1 �t7 �I S-� KQ' Vyaiyec SUBDIVISION NAME
DIFJ§CTIONS TO
h&j
/i
LOT #
uS
NAME SYSTEM INSTALLED UNDER t!1'q .e
DATE SYSTEM INSTALLED 06
TYPE FACILITY MvilUU-MBER BEDROOMS NUMBER PEOPLE SERVED `3
TYPE WATER SUP P Y I SPECIFY PROBLEM OCCURRING 11'Ale- A) 00 S
Al i/V L.5
DATE REQUESTED
INFORMATION TAKEN BY (L U(
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. 1/93
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http://maps.co.davie.nc.us/GoMaps/map/map.cfm?CFID=4129&CFTOKEN=61640881 6/30/2011