190 Homestead LnDAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680
REPAIR OPERATION PERMIT
Account #: 990005716 Tax PIN/EH #: 5767 -67 -7768 -Repair
Billed To: Billy Mason Subdivision Info
Reference Name: PERAIR PERMIT Locaiion1Addres9 190 Homestead Lane -27028
Proposed Facility: Residential -Repair Property Size: - 12.17 Acres
ATC NuVer- 5797
**N E" 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: .Lt' S.T. Manufacturer t Tank Date Tank Size
Pump Tank Size /
System Installed Byh ky.ld E.H. Specialist: ate:l
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
REPAIR IMPROVEMENT PERMIT
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990005716 Tax PIN/EH M 5767 -67 -7768 -Repair
Billed To: Billy Mason Subdivision Info:
Reference Name: REfkAIR PERMIT LocalioniAddress:' 190 Homestead Lane -27028
Proposed Facility: Residential -Repair Property Size: 12.17 Acres
ATC Number: 5797
**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
oir the intended use change.
Residential Specifications: # Bedrooms 3 # Bathrooms")-- # People Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size 1�,.! �' �`"' Type of Water Supply: ❑County/City EAVell ❑Community Well
System Specifications: Design Wastewater Flow (GPD) GC)Tank Size 0GAL. Pump Tank /V)4 -GAL.
Trench Width 3 t, Max. Trench I�epth3 Rock DepthlVA Linear Ft. --�
Site Modifications/Conditions/Other: As stated in 15A NCAC 18A..1969(5)
Contact the Davie County Environmental Health Section for final inspection of this system bet,
8:30 — 9:30a.m. on the day of installation. Telephone # (336)753-6780.
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Environmental Health Specialist �i / Date:
DCHD 11/06 (Revised)
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DAVIE COUNTY ENV ONMENTAL HEALTH SECTION
t :: % n/APPLICATION R I PR ENT PERMIT (REPAIR) /
NAME �"' /V'4141 x/ " �� /�lla�l� PHONE NUMBER
ADDRESS e SUBDIVISION NAM f
�7�07 �� - LOT # 'a 17��
DIRECTIONS TO SITE LJ1 0 91, 0/0/
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DATE SYSTEM INSTALLED jqi9q NAME SYSTEM INSTALLED UNDER
TYPE FACILITY >✓ NUMBER BEDROOMS A NUMBER PEOPLE SERVED
TYPE WATE SUPPLY 1/V �`` SPECIFY PROBLEM OCCURRING k a1 /V11
k It off_ I 17
DATE REQUESTEINFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge. and that
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93
I am responsible for all charges incurred from this application.
7
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http://maps.co.davie.nc.us/GoMaps/map/map.cfm?CFID=4129&CFTOKEN=61640881 6/24/2011
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