733 Greenhill 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 #: 989900113 Tax PIN/EH #: J300000043
Billed To: Floyd Green Subdivision Info:
Address: 72 Greenhill Road Location/Address: 733 Greenhill Road -27028
City: Mocksville Property Size: 0.451
Reference Name: Floyd Green
Proposed Facility: REPAIR
**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.
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System Type: S.T. Manufacturer Tank Date Tank Size
Pump Tank Size_
System Installed By: E.H. Specialist:hW,§ate:j9W"
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
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 989900113 Tax PINIEH #: J300000043
Billed To: Floyd Green Subdivision Info:
Reference Name: Floyd Green LocationrAddress: 733 Greenhill Road -27028
Proposed Facility: REPAIR Property Size: 0.451
ATC. Number: 5835 Site Type: ❑New XRepair ❑Expansion
**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 change.
Residential Specifications: # Bedrooms/ # BathroomsJ_ # People Basement❑ Basement plumbing
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size .LJ6'0.(, Type of Water Supply: OCounty/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow (GPD) 7 O Tank Size GAL. Pump Tank ad GAL.
Trench Width u_ Max. Trench Depth SV Rock DepthN10 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.
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Environmental Health Specialist Date:
DCHD 11/06 (Revised)
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AUTJ-lu _ IZATION'NO:r' DAVIE�,OUNTY HEALTH DEPARTMENT
540
Environmental Health Section PROPERTY INFORMATION
Permittee 's P.O. Box 848
Name: _ Mocksville, NC 27028 Subdivision Name:
•� Phone # 336-751-8760
Directions to property: ' , ��; *i'-'_ . �% Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION 2
Roadd� e:�t✓Yt - 0
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office .when applying for Building Permits.
(In compliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
DAVIE OUNTY HEALTH DEPARTMENT
TMPRO EMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittee's;..
Name�.�-^' �1..�'" ,�� Subdivision Name:
.Directions to property: ' 'r ! Section: Lot:
IMPROVEMENT
1` PERMIT Tarx� Office PIN:# - -
Road Name: e. )I
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the.
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
- ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE V
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH ! `LINEAR FT./
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
Q
Ecc
NTACT 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 THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
Q
AUTHORIZATION NO. _C OPERATION PERMIT BY: DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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.
DCHD 05/96 (Revised)
r.�9 0 DAVIE OUNTY HEALTH DEPARTMENT
J IMPRO EMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittee's
Name:Subdivision Name:
Directions to property: = ' Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#
Road Name, .r- , E' 1 f Nip: w r Ci
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
# BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE
# PEOPLE
# PEOPLE/SHIFT
# SEATS INDUSTRIAL WASTE: Yes or No
NEW SITE REPAIR SITE
LOT SIZE TYPE WATER SUPPLY
DESIGN WASTEWATER FLOW (GPD)
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SYSTEM SPECIFICATIONS: TANK SIZE GAL.
PUMP TANK
GAL. TRENCH WIDTH .
ROCK DEPTH LINEAR FT.
'(
�'; 1
OTHER // �! l
r• j/. .` ;'1
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
cz
"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 THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT
d
SYSTEM INSTALLED BY:
—1�.iU
AUTHORIZATION NO. OPERATION PERMIT BY:
"*THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 O 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.
DCHD 05/96 (Revised) _ .r
AUTHOkl` ATION NO: 0960 VIE COUNTY HEALTH DEPARTMENT
P, l 4 Environmental Health Section PROPERTY INFORMATION
Permittee's -J/ �-�/ P.O. Box 848
Name: e Gni" r'r t' Mocksville, NC 27028 Subdivision Name:
Phone #: 704-634-8760
Directions to property: /A Section: Lot:
t1 AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# - -
SYSTEM CONSTRUCTION
Road Name: f—de. n h riQ
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
•
�AVIE COUNTY HEALTH DEPARTMENT
Ai4PROVEMENT AND OPERATION PERMITS
Permhtee's
PROPERTY INFORMATION
Name:, y P 1 "! ' Subdivision Name:
Directions to property: J Section: Lot:
IMPROVEMENT
PERMIT Tax Office PINI1:# _
Road Name: (�r-'ee)t J) NJ'
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
F ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
7 s: /e a PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE TELLS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE _ # BEDROOMS ? # BATHS ? # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY �? DESIGN WASTEWATER FLOW (GPD) NEW SITE,_REPAIR SITE t/
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH :P • ROCK DEPTH Z -2L LINEAR FT.. C�
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
"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 THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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.
DCHD 05/96 (Revised)
` r DAME COUNTY HEALTH DEPARTMENT
/IMPROVEMENT AND OPERATION PERMITS
Permfttee's
PROPERTY INFORMATION
Name: % € t r - Subdivision Name:
Directions to property: Section: Lot:
IMPROVEMENT
F PERMIT Tax Office PIN:# J j
Road Name: `SLI—e-E'_m / ;/ � 1Zip:
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE A/ # BEDROOMS c # BATHS --? # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFr # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE - GAL. PUMP TANK GAL. TRENCH WIDTH._ �+ r/ROCK DEPTHY `y " LINEAR FT. t'
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
"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 THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT
AUTHORIZATION NO. 19r OP
5
"THE ISSUANCE OF THIS OPERATION P:
WITH ARTICLE 11 OF G.S. CHAPTER 130?
SYSTEM INSTALLED BY:
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1
GUARANTEE THAT THE SYSTEM WILL
4
DCHD 05/96 (Revised)
DATE: 7? r
?MIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
NCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
r _,
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
/ /
WORKSHEET FOR SEPTIC SYSTEM REPAIR PERMIT
NAME_ 1�Ng (�reen. PHONE NUMBER
ADDRESS SUBDIVISION NAME
UBDIVISION LOT #
DIRECTIONS TO SITE Aii[p-k-� - % fiivc-o vir
DATE SYSTEM INSTALLED
NAME SYSTEM INSTALLED UNDER
SPECIFY PROBLEMS OCCURRING
DATE REQUESTED INFORMATION TAKEN BY
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NAME <326W(v�
ADDRESS Z
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
WORKSHEET FOR SEPTIC SYSTEM REPAIR PERMIT
?�h/O PHONE NUMBER
� o ,. f%0J SUBDIVISION NAME
e . fvlk�
SUBDIVISION LOT #,
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED
NAME SYSTEM INSTALLED UNDER
I SPECIFY PROBLEMS OCCURRING
DATE REQUESTED to INFORMATION TAKEN BY
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