153 George Jones Rd` DAVIE COUNTY ENVIRONMENTAL HEALTH VA4
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028 A
(336)753-6780 / Fax # (336)753-1680 n
REPAIR OPERATION PERMIT (J•
Account #: 990002687 Tax PIN,/EH #: 5758 -89 -1006 -Repair
Milled To: Daniel Perrell Subdivision Info:
Reference Name: LocationiAddress: 153 George Jones Road -27028
Proposed Facility: Residental-Repair Properly Size: 12 + Acres
a,T1�fih���s�r ce 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 IV Tank`,Date� Tank. Size
Pump Tank Size
System Installed By: Nor�ra�S ST E.H. Specialist:
GPS Coordinate:
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 #: 990002687
Billed To: Daniel Perrell
Deference Name:
Proposed Facility: Residental-Repair
Tax PINiEH #: 5758 -89 -1006 -Repair I
Subdivision Info:
LocationiAddress: 153 George Jones Road -27028
Properly Size: 12 + Acres
Site Type: ❑New Repair ❑Expansion
ATC Number: 5729 R
**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 chance.
Residential Specifications: # Bedrooms # Bathrooms # People '7
4,- Basement❑ Basement plumbing
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size Type of Water Supply: ❑County/City EgWell ❑Community Well
System Specifications: Design Wastewater Flow (GPD)�O Tank Size AL. Pump Tank GAL.
r 1 t
Trench Width_ Max. Trench Depth&L Rock Depth Z Linear Ft. 2�
Site Modifications/Conditions/Other:
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.
I
Environmental Health Specialist lw Date:!
DCHD 11/06 (Revised)
" ff6/ W-6727
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
Q� / J�
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) dell
NA (� %ZlC_T L�iL%Z�`� PHONE NUMBER 76f_46 ly✓
ADDRESS 153 TGb/G)P_�Ti1toSI • MOCkVI'lleSUBDIVISION NAME
LOT #
DIRECTIONS TO SITE la
DATE SYSTEM INSTALLED .-` NAME SYSTEM INSTALLED UNDERIU�- /SIL/ZCG�
TYPE FACILITY s'le— NUMBER BEDROOMS 3 NUMBER PEOPLE SERVED
TY E WATER SUPPLY SPECIFY PROBLEM OCCURRING
YA i�
DATE REQUESTED D "�l INFORMATION TAKEN
W"IF
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
GoMaps GIS
Page I of 6
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http://maps.co.davie.nc.us/GoMaps/map/map.cfm?CFID=4129&CFTOKEN=61640881 1/28/2011