274 Gun Club Rd' 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 #: 990005719 Tax PIN/EH #: 5871-06-1429
Billed To: James Williams Subdivision Info:
Reference Name: REPAIR PERMIT Location/Address: 274 Gun Club Rd -27006
Proposed Facility: Residential Repair Property Size: 2 Acres
ATC Number: 5800
**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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• 1System Type: -�� S.T. Manufacturer ��� Tank Date Tank Size
Pump Tank Size
System Installed By:�= QV`Z2\ �'i' " E.H. Spec . 4/&dte:
GPS Coordinate:
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DCHD 11/06 (Revised)
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DAVIE 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 #: 990005719 Tax PIN/EH #: 5871-06-1429
Billed To: James Williams Subdivision Info:
Reference Name: REPAIR PERMIT Location/Address: 274 Gun Club Rd -27006
Proposed Facility: Residential Repair Property Size: 2 Acres
ATC Number: 5800
**NOTE** This IP/ 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 IP/ AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat
oT the intended use change.
Residential Specifications: # Bedrooms # Bathrooms—L-J # People c)- Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size o /L"�" Type of Water Supply: 9-County/City ❑Well ❑Communi Well
System Specifications: Design Wastewater Flow (GPD) ? 6Tank Size _1 L-6 5 01E x -
GAL. Pump
TankAJl AL.
Trench Width3L Max. Trench.Depth_
Rock Depth I "Linear Ft.
15A NC
AC .".tptt�ted`irr iiC
Site Modifications/Cond�tilons/Other: Ci;rl + „r ��t �n #v �'sn
r�s
Contact the
County Environmental Health Section for final inspection of this system between
i— 9:30a.m. on the day of installation. Telenhone # (336)753-6780. "\
Environmental Health Specialist
DCHD 11/06 (Revised)
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Date:
livvoice ' 909
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) �y
`-�n�i��J I f� S PHONE UMBER
NAME f�I'I E N � <ZI
t? -C- SUBDIVISION NAME
j LOT #
DIRECTIONS TO SITE/'/J �I L�� 9�lTi 4
wee 7$ re) iUf'a1 f'pa,, �cK
DATE SYSTEM INSTALLED l "l 7l d b NAME SYSTEM INSTALLED UNDER `JOhar1 q F. 1 I11A
TYPE FACILITY JWih NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY ( SPECIFY PROBLEM OCCURRINGs2a1O- 1;N6 S
DATE REQUESTED INFORMATION TAKEN BY,
This is to certify that the information provided is correct to the best of my knowledge, and that I
SIGNATURE OF OWNER OR AUTHORIZED AGENT,
Rev.1/93 �^
-�7 ('4-
incurred from this application.
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http://maps.co.davie.nc.us/GoMaps/map/map.cfm?CFID=4129&CFTOKEN=61640881
7/8/2011
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