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997 Baltimore Rd DAVIE COUNTY ENVIRONMENTAL HEALTH . P.O.Box 848/210 Hospital Street SUl Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 REPAIR OPERATION PERMIT Account-#: 990005863 Tax PIN,EH#: F711OA0004 Billed To: Cathy Stroud Subdivision Info: Baltimore Acres Lot#4 Reference Name: Replace Partical Septic LocationiAddress:,: 997 Baltimore Road-27006 Proposed Facility: Residential- Relocate Property Size: • 1 15',Acres ATC Number: 5920 **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC has been installed in compliance with Article I 1 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: `(��A "�LD ,Q I� Inspector#: Date: GPS Coordinate: f Id Environmental Health Specialist: PU RA40 Date: 1201, 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 #: 990005863 'fax PIN, H#: F711 OA0004 Billed To: Cathy Stroud Subdivision Info: Baltimore Acres Lot#4 Reference Nance: Replace Partical Septic LccationiAddress:. 997 Baltimore Road-27006 Proposed Facility: Residential- Relocate Property Size: 1.15 Acres Site Type: ❑New %Repair ❑Expansion AT* �WrThis AuOthorization 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 #PeopleBasement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size C_ Type of Water Supply: County/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD)3WTank Size A.L.Pump Tank GAL. rx Y Trench Width Max. Trench Depthi Rock Depth Linear Ft._23 Site Modifications/Conditions/Other: Contact the Davie County Environmental Heilth Section for final inspection of this system between 8:30-9:30a.m.on the day of installation. Telephone#(336)751-8760. x�� t bas rok Environmental-Health Specialist Date: DCHD 11/06(Revised) Davie County Health Department ��►s r � Environmental Health Section � ECEIVC4 - P.O. Box 848 .�y J210 Hospital Street P A'R t�►(a 20rourier# 09-40-06 A APR ? 0 ;M j;) 1911 cksville, NC 27028 D &&&j _9A Al Phone:(336)-753-6780 ON-SITE WASTEWATER CERTIFICATION Fax:(336)-753-1680 (Check One) Replacement Remodeling Reconnection ;33& - `V-- --- 0g18 (F`r Name: (Ad :3:310 _ (!L//-Phone Number 3 5 (Home) I Mailing Address: �1, / ,� /!/1�Q c -Ct� � 1Q • _t. L1 (Work)-k f-hd VO 1/)((`P JC 0-766(, Email Address: /S'7w ue%�j�Qd e-olIll'Q) Detailed Directions To Site: 5 b 154;4'M0(-e_ ( J' — 00 tei!T Il Property Address: g 7 / lr awo Please Fill In The Following Information``About The EXISTING Facility: �j Name System Installed Under: i�� ly-u 1 OiJ Type Of Facility: Date System Installed(Month/Date/Year): t' ( Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? Yes N- V If Yes,For How Long? Any Known Problems? Yes 4-9 If Yes,Explain: Please Fill In The /Following Information About The NEW Facility: Type Of Facility: `N�Q i Number Of Bedrooms:2_Number of People Pool Size: ICI �� Garage Size: (5k Other: Requested By: �7LIaud Date Requested: IZ© Zd (Signature) For Environmental Health Office Use Only eprovedisapproved _ Comments: el y Environmental Health Specialist Date: d *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 ecMoney Order # Amount:$ Date: Paid By: -f �/`v, Received By: � jJ6( Lr�jl �2 Account#: Invoice#: �� I NSI --Ajq('i3 rF Davie"County Health Department 1836 j� Environmental Health-Section .; P.O. Box 848 210 Hospital Street O Courier# : 09-40-06 1911 Mocksville, NC .27028 Phone:(336) 753-6780 ON-SITE WASTEWATER CERTIFICATION Fax:(336)-753-1680 (Check One) Replacement Remodeling Reconnection Name: r`Q��1� Phone Numb 3 3(1� " ���— 3 J�3 (Home) Mailing Address:. ''! -/ /� ( ( r �n 11 (Work) Hya a(y Email``A�d-dress: � Detailed Directions.To Site,,, � /�g /y')o f zk Pro perty Address: 9' 7 / /�?., y VQ��� AC a ' iV y i y, . . Please Fill In The Followin Information About The EXISTING Facili g t3'; � . Name System Installed Under:_��� �Q 5i'lu�7 l bti ;Type Of Facility: Date System Installed(Month/Date/Year): ( ) Number Of Bedrooms:` Number Of People: ` { Is The Facili Currentl Vacant? Yes ' N ,... g ty. yfIf'Yes For How Lon • ., Any Known Problems? Yes �N� If'Yes,Explain: Please Fill In The Following Informatign Abdul The NEW Faci�ilj7:�,,, Type.Of Facility: `N v o � —Number Of Bedrooms: o� Number of People 1 ` �� r /; Pool Size.' i'� � /` Garage Size: ' �, C'Q'r Other: " Requested By: •j Date Requested:_ ` (Signature) For Environmental Health Office Use Only proved Disapproved •- ' r Comments:. Environmental Health Specialist ,f/ ' Date : *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 s stem will function ro:�erl for an iven eriod of time: � ) Y P P Y Y g� P Payment: CashL ec Money Order-# Amount:$ r' Date; �-7�— Paid By: C( —fif v `Receiveci:$y. Qd Y r (Ll x /�n fes- —GL • Account#: > a ,