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112 Gray Sheeks RdDAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 REPAIR OPERATION PERMIT Account #: 989900029 Tax PIN/EH #: D700000194 Bilied To: Potts Realty Subdivision Info: Reference Name: REPAIR PERMIT Localion!Address:''1"12 Gray Sheeks Road -27006 Proposed Facility: Residential Repair Property Size: 4.4 Acres ATC Number: 5929 **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: �j r /�A (�� Inspector#: Date: ?/2O/Z GPS Coordinate: Environmental Health Specialist: DCHD 11/06 (Revised) Date• Zz 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 #: 989900029 Tax PIN."EH #: D700000194 Billed To: Potts Realty Subdivision Info: Reference Narne: REPAIR PERMIT LocationiAddress: '112 Gray Sheeks Road -27006 Proposed Facility: Residential Repair PropAf lkF: llaj4wq Pair ❑Expansion 4l UUR2q **�Q T ** Thi horization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental AT ea7�S cl�ion �Nto.issuance of any building permit(s); (in compliance with Article I 1 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 # People Basement❑ Basement plumbing[] Non -Residential Specifications: Facility Type # People # Seats_ Square Footage(or Dimensions of Facility) Lot Size ` Type of Water Supply: 19county/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow (GPD) %Tank Size GAL. Pump Tank GAL. Trench Width Max. Trench Depth Rock Depth Linear Ft. 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. t 1 X WNQ_�*ltmP tai Environmental Health Specialist DCHD 11/06 (Revised) -� wa r'd(tt 16" i.� Pipe is b1o��i �I�C CC ^'000- W Date: "5—// / 2 tm rt'? ro&/I ov, ,S©VJ 0 m,,1 -1;1V4 • �'0' 3Qx-Irl9Y /d 11dti6e, eve ,Z7an,6 DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST -� G APPLICATION IP/ATC OSWW REPAIR W0 -,2-�OD n G Name b1� Telephone Number Address Z G'% he -e 6' Ald ya y e e, Mailing Address (if different from above) Email Address: Subdivision Name Lot # Directions I (/(l / 5� 1AI' 2 _ DN / Nco five/1' Date System Inst le %� �� Name System Installed Under Type Facility Number Bedrooms 3 Number People Served Type Water Supply Specific Problem Occurring �q �J&&;/ q 2 Date Requested - 6 -- Z Info Taken By THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY KNOWLEDGE, AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED FROM THIS APPLICATION. Signature of owner or Authorized Agent Initial Fee Date REHS Revisit Charge Date Reason Revised 2-2011 Ps Rax-I/9Y l/Yi119 v1 --4P IV(", -21M'6 DAME COUNTY ENVIRONMENTAL�HEAL-TH SERVICE RE UEST r APPLICATION IP/ATC1 OSWW REPAIR INT-;Yoo Name kub i Telephone Number Address 2 &-1.4 j1 El C.1 (/ar E' Mailing Address (if different from above) Email Address: Subdivision Name ,r O/' Lot # Directions [�Y l C� /� w y /1(/ / / �� '� 9 I /ice Oyu k2 QA/ /NC/ Date System Inst led Name System Installed Under Type Facility- d jt Number Bedrooms Number People Served Type Water Supply 62 t Specific Problem Occurring AT /41ZV t/IAI Date Requested Z- Info Taken By,61'� THIS IS" TO CERTIFY T#AT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY KNOWLEDGE, AND Tff' kT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED FROM THIS APPLICATION. Signature of owner or Authorized Agent Initial Fee;Date `�•.�, �. , REHS Revisit Charge Datey Reason Revised 2-2011 q�qq 000e GoMAPS - Davie County NC Public Access - E ; r' �r l ti..• 0rpf fF r i ^ ' I•:L'RCIiANT LN n �l _�-1- - HILLSDALE ';,LST DR \ 5rt DINC; IIA rll-: PARKD (�o20tft I BERMUDA RUN ***WARNING: THIS IS NOT A SURVEY!*** This map is prepared for the inventory of real property found within this jurisdiction, and is compiled from recorded deeds, plats, and other public records and data. Users of this map are hereby notified that the aforementioned public primary information sources should be consulted for verification of the information contained on this map. The County and mapping company assume no legal responsibility for the information contained on this map. Jk L WATERSHED STRUCTURES WATER -BODIES COUNTY_ BOUNDARY STREETS tr, . RAILROAD -CENTERLINE a PARCELS CITY -LIMITS DAVIE <all other values> Monday, April 30 2012 BERMUDA RUN COOLEEhtEE DAVIE COUNTY MOCKSVILLE nccountics DAVIE <all other values> Monday, April 30 2012