402 Gun Club RdDAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680
Account #: 990002620
Billed To: Julia Childs
Reference Name: REPAIR PERMIT
Proposed Facility: Residential -Repair
REPAIR OPERATION PERMIT
Tax PICU/EH #: 5871-06-8053
Subdivision Info:
LocatibniAddrss: 4022 Gun Club Rd -27006
Property Size - /: /5 A,,
AT(*1tT0r* ThRs19ance 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.
gystem Type: _�L S.T. Manufacturer Tank Date Tank Size
Pump Tank Size
System Installed By: C E.H. Specialist: :--`�Cll
GPS Coordinate:
DCHD 11/06 (Revised)
r 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 #: 990002620 Tax PIES/EN #: 5871-06-8053
Billed To: Julia Childs Subdivision Info:
Reference Blame: REPAIR PERMIT LocalioniAddress: 4022 Gun Club Rd -27006
Proposed Facility: Residential -Repair. Properly Size:, ,.
Site Type: ❑New XRepair ❑Expansion
ATC Number: 5739
**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 # Bathrooms # People Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size 14 ac Type of Water Supply: Xcounty/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow (GPD)366 Tank Size�NAL. Pump Tani* GAL.
Trench WidthMax. Trench Deptl�6►' Rock Dep11thj(yff Linear Ft..350(A
Site Modifications/Conditions/Other: e�?3_� 6In
Contact the Davie County Environmental Health Section for -final inspection of this system between
Environmental Health S
DCHD 11/06 (Revised)
MOO- rssu Z12-0_3 /IOW 1A151r.Q.,(-to,
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION j,(,(1��'L r%��iZ✓���
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) ,///
NAME � S PHONE NUMBERAM& 140- �ryi
ADDRESS &-uadge- SUBDIVISION NAME 1poj1jpt 1,ille
ii ,�' / LOT #
I
DIRECTIONS TO SITE l5 6(J l9'/,/�lI �1 GGA✓ j%Irt� Ir %�/l-1-
DATE SYSTEM INSTALLED ,, NAME SYSTEM INSTALLED UNDER
TYPE FACILITY -J& NUMBER BEDROOMS NUMBER PEOPLE SERVED 2 -
TYPE
TYPE WATER SUPPLY YI� SPECIFY PROBLEM OCCURRING UA.Or QA/ -I(dn elP
DATE REQUESTED �' INFORMATION TAKEN BY
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
Permittv's ', s DAVIE COUNTY HEALTH DEPARTMENT
Ntme: '% Environmental Health Section PROPERTY INFORMATION
ti P.O. Box 848
Directions to property: �� 1L' t t" "' Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section: Lot:
/ AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN:#
AUTHORIZATION NO: �"' " A Road Name: if �i i t' jZ p t c !
**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)
F / ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONNiEN-VL H ALTH SPECIALIST,) DATE ISSUED
IL r �
RESIDENTIAL SPECIFICATION: BUILDING TYPE MVEUROOMS #BATHS Z- #OCCUPANTS.._'.!'� GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
�
LOT SIZES �`' °� &0TYPE WATER SUPPLY 7�� DESIGN WASTEWATER FLOW (GPD)---�rtr
� NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH 1L LINEAR FT.�- '
OTHER 1 i , `-�j^t 1 ` 4+ 1 I O r� C _.i '�-'� , i IJC-i 1t ,I _ i .-Irk' t L , i (n.i ,
REQUIRED SITE MODIFICATIONS/CONDITIONS: *L � � , � V -a 1-, JL
IMPROVEMENT PEMT-LA-YOUT
MPROVEMENTPOUT
fc
err" _ li t --.Sc o L%-r:CX. 5, NOT h I^i:i) 1,3 L-A-� r
VJ1 `�
11Lr C
M ►j
JT
"CONTACT
**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
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 02/02 (Revised)
4
P
erin�it DAME COUNTY HEALTH DEPARTMENT
Name:xEnvironmental Health Section PROPERTY INFORMATION
P.O. Box 848
Direttibri§Jo property: Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION Tax Office, P.IN:#- -
Zr
p:
AUTHORIZATION NO. t v
A Road Name:x L k,
**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 FormJAuthofization Number should be presented to the; Davie CouAty 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)
***NOTIC-V** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
'ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE ML L iADROOMS # BATHS G # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFF— #SEATS INDUSTRIAL WASTE: Yes or No
of
LOT SIZE C, TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE V
SYSTEM SPECIFICATIONS: TANK SIZE —GAL. PUMP TANK _GAL. TRENCH WIDTH— ROCKDEPTH—t',— LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
L
a
N
J
P
4
Ly
11— J
J. I
"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
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 I I 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 02/02 (Revised)
VIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
PO Box 848/210 Hospital Street
Mocksville, NC 27028
Phone: (336)751-8760
ASTEWATER CERTIFICATION FOR DWELLING
V___,(C-1fe—ck One) REPLACEMENT ❑ REMODELING ❑ RECONNECTION ❑
Name: 'J w"� ._ J Phone Number: J yo QFC// (Home)
Mailing Address: tf o �ti n C / ,--e Pv Ad u, het -7-7 - D 0 / 4 (Work)
Detailed Directions To Site: / 4 0 -� ! S r� S -4. I
s `" C- :rte r i .2 riu S �- �D S S !' I /l s cf d -e f� c,A f C 4 L_ G r� CMZ cLn C / .�'
r
r- l..i— f St-� 1-2,2-e, 1!4 n— s t 04A�
Property Address: 4740---)_ I "n I- LL,---?
Please Fill In The Following Information About The Existing Dwelling.
Name System Installed Under: It 14 N /L e Type Of Dwelling: �tlr%-r/ e wj
Date System Installed(Month/Day/Year): l S 7 -� Number Of Bedrooms: •� Number Of People: 3
Is The Dwelling Currently Vacant? Yes ❑ No C9-'�If Yes, For How Long?.
Any Known Problems? Yes ❑ No [f' If Yes, Explain:
Please Fill In The Following Information About The New Dwelling: /
Type Of Dwelling: a �'(� Number Of Bedrooms: Number Of People:
CP
Requested By: Date Requested: 1-0-3
(Signature)
Approved ❑
For Environmental Health Office Use Only
Disapproved ❑
I SS.Lk1')
Environmental Health
o3
*The signing of this form by the Environmental Health STaff is in no way ihtefided, nor should be taken as a
guarantee(extended or limited) that the on-site wastewater system will function properly for any given period of time.
Payment: Cash ❑ Check Money Order ❑ #j c 6 y Amount: $ � Date:
Paid By: Received By:
Account #: n �--� -_ Invoice #: .
t
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
PO Box 848/210 Hospital Street
MocksviRe, NC 27028
Phone: (336)751-8760
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMENT ❑ REMODELING ❑ RECONNECTION ❑
Name: 4—e 11 f Phone Number: � `.3 (Home)
Mailing Address: Q --1- 6u n �' l' "' Ac'C.P he 77 p �; (Work)
Detailed Directions To Si
m^1\ 1 59, - -C-
-/ o l=- +r, %Jc.,, _, r_,`0 / �Q ,% t ._r, t- S �v ;, ) i
_S n.� _S `4 / l // s r/ t� o 11 c.;: f ti L-) c n K-7 d
7, i'� i r� +� ' r , � l�_f-- � i f �a /'n..,,,�r i-•� /!.. t r- n ;'� ��tJ�-// P �,�'
Property Address: a �__ (�! cr n r t,
Please Fill In The Following Information About -The Existing Dwelling.
Name System Installed Under: (I Type Of Dwelling: —S i r, r
Date System Installed(Month/Day/Year): ) S 7 ? Number Of Bedrooms: Number Of People:
Is The Dwelling Currently Vacant? Yes ❑ No ff-' If Yes, For How Long?
Any Known Problems? Yes ❑ ' No ❑'" If Yes, Explain:
Please Fill In The Following Information About The New Dwelling.
Type Of Dwelling: /C11 Number Of Bedrooms: Number Of People:
Requested By: Date Requested:
(Signature)
For Environmental Health Office Use Only
Approved ❑ Disapproved ❑ 2 1
Comments:
Environmental Health Specialist ! -1'i Date Lv /L)5
"The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a
guarantee(extended or limited) that the on-site wastewater system will function properly for any given period of time.
Payment: Cash ❑ Check Money Order ❑ #� {) (1 y Amount: $ U �. Date: 24� la
Paid By: Received By:
Account #: "�,� _1- �� Invoice #: _ 1 ,)
FEB -19-2003 09:26 SECU WINSTON SALEM 11 336 773 0740 P.01i01
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
PO Box SWID Hospital Street
Mocksville, NC 27028
Phone: (336)752-8760
ON•SrM WASTEWATE ERTiFICATION FOR DWELLING
(Check One) REPLACEMENT REMODELING 0 RECONNECTION 0
Name:];aj I •i s Phone Number_ -_. 0_ / 'IJ- Z
' r(Home)
Mailing Address: ► 3310-:223-60/6 ((Work)
Detailed Directions �
To 5ite:�`
40
AA- 115&s s
Property Address LX__F_
�
Please Fill In The Following Information About The Existing Dwelling.
Name System Installed Under: �,I I Y _ `!e6 J it h Type Of Dwelling-
Date
wellingllJ 1(l
Date System lnstalled(Month/Day/Year): ..L 9 � Number Of Bedrooms:_ Numb,, Of People•_
Ls The Dwelling Currently Vacant? Yes 0 NoVf"" 14 Yes, For How Long?
Any Known Ptoblems7 Yes 0 Nwe' if Yes, Explain:_
Please Fill In The Following Information About The New Dwelling; a
Type Of Dwelling: 6 N AW__ Number Of Bedrooms:, �.1__Number O# People J
,,R4uested By �j Date Requested:
(Signature)
For Environmental Health Office Use Only
Approved 0 Disapproved 0
Comments:
Environmental Health Specialist Date
'The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a
ftwantee(extended or limited) that the on-site wastewater system will function properly for any given period of time.
Payment: Cash 0 Check 0 Money Order n N Amount: $ Date:
Paid By: Received By:
Account M:
Invoice a:
TOTAL P•01
9195 r
w 871 W
00 413 r
> 1 N �
e . 4,5 X1191�
91204.
�. 412
7 � y
28 6
2
'o� X43 Q 55
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3918
00
5 428
r 56 �� 3 �� 83
8960 0
bo4 ..�a
a 184 4 s y 77 48
3835 0894 N
6870 8840 y,-- a
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4 141,74 ,
4763 '
6
8649 9687 . ,0791 r
3657 0 2616 4� . 4
"
135 aar 190
61 8 122 2 439 ' 8'1 4.,a 2 36.52 �
1 53
: 35164
441 4J`
9539 Q5 3 1533' '30 �s
t 25312
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3403 441 .,
t 1
m 5395
�o 4
333 0320 1302
1288
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444
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4 .
97 o .� 9,
235.49
CO a 6104 .g;. rQ �2
3102
9
o ..
07 6023 M � 446
8 53 4 AL
56r^1,
60 V _
, rw m ry
29 -�
$ a
o
x
7
48 3 �
M
-.. f 105.77 1 ;
*11 1A , w X11 6
,. o
_01
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oc,
:.
(6.82A) 'n
E &° 950 -57
8
4
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K
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(68 126 (70) 95
1
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§203
5282 1
ti
117 128
E
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