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385 Madison Rd ' 1 � DAVIE COUNTY ENVIRONMENTAL HEALTH � '"°'� P.O.Bpx 848/210 Hospital.Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT Account #: 990000916 Tax PIN/EH#: 5729-71-6354 � Billed To: John Didenko � Subdivision Info: Reference Name: ` Location/Address: 3�5 Madison Road-27028 � Proposed Facility: Residence_ Properry Size: 1.00 Acre � ATC Number: 2642A **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 sball 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 �c.��`5 � � System Installed By: �����e-^''E.H. Speci ist: l� / , - '�'�`�•LI r�� ��c�—S = 1 la�' ��2` � ,��3G s - ��Z� ; �U lct� `� � �� . ✓� Tn� \ �'•� � , � � ...� ' � � , +` � G� .�� ���,�� ;; y! , .�i ��� � . : � � �r DCHD 11/06(Revised) �,� . .. � � ��(N ) ' f. : . ,� . , - DAVIE COUNTY ENVIRONMENTAL HEALTH . P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 AUTHORIZATION FOR WASTE`VATER SYSTEM CONSTRUCTION Account #: 990000916 � Tax PIN/EH#: 5729-71-6354 ' Billed To: John Didenko � Subdivision Info: Reference Name: ' Location/Address: 385 Madison Road-27028 � Proposed Facility: Residence Property Size: 1.00 Acre ATC Number: 2642A SiteType: ONew,�Repair ❑Expansion **NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building pemut(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 � #Bathroo�•�#People� Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) � Lot Size Type of Water Supply: ounty/City ❑Well ❑Community Well Q System Speci�cations: Design Wastewater Flow(GPD) ��I'ank Size GAL.Pump Tank GAL. Trench WidthT�o� Max.Trench Depth�� Rock Depth� A Linear Ft. 2�'S� Site Modifications/Conditions/Other• r ��=� i-� o ����a^� �y �C�`'`�' ���'���� FwvJ v,a...�� o' . L�t Contact the Davie County Environmental Health Section for�nal inspection of this system between 8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760. � �� ' ��y !� �� ` �� ��S ��P�G A-iL � �0 �p�����G� ��� � � � � � ,SS�� � � � D � = � - 3� �,� � ,� �--lo,.�x �( , � � . t ' ' � sr ,� _ . � � ��F�'�` � ..r .� — I ��/L�,�c, lYt�� ia' � � � _ ri0 Y�uk � .� ; r ��� - _ . _ �.� ��-PAa,�a � Environmental Health Specialist e� �g ��`�iV 1���) ; nCHD 11/06(Revised) � . :. . __. .� , . : , , . . , ; , .. ,....;. . . . _ ,.��- ;., Pecmit�ee's�,�•-' ' � ' i . �IE'COUNTY HEALTH DEPARTMENT ��< Name:��(l�/1 ` . �I e �� Environmental Health Section PROPERTY INFORMATION D� �.', .. . _ � .:�, � .' , _ � � P.O.Box 848 �/��� D's�ections'to pmperty:�_ � � �tl�� Mocksville,NC 27028 Subdivision Name: V` � `. `. j;, � j , �'.."r.M�Phone#:336-751-8760 , f`. .r` � ..4r / /i� ��' � . Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTF.M CONSTRUCTION ����l n Y AUT�IORIZATION NO: ��+���� A Roa Name: Zip:� **NOTE**This Authorization for Wastewater System Construction MUST$E ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits.This Form/Authorization Number should be presented to the Davie Counry Building Inspections Office when applying for Building Permits. (ln compliance with Anicle 1 I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) i �� �� f,' . .:-��� „�' ,/ �d' ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ir���f�'; -�'' �'L� �,�`.:�-�°�� 1 �f ��3 IS VALID FOR A PERIOD OF FIVE YEARS. � �.. f T_ . . � . . . � � . ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION:BUILDING TYPE� #BEllROOMS�#BATHS��#OCCUPANTS�GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLEISHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE TYPE WATER SUPPLY� DESIGN WASTEWATER FLOW(GPD)L� NEW SITE REPAIR SITE� 1, SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH� ROCK DEPfH��LINEAR FI'.� OTHER L►' C�'%fS �' � H-�1' -. '� ' i 7P� ,.��. " "� l � r.. _ . REQUIRED SITE MODI�FI��t S�CONDITIONS: Q P I�7 �� " �� IMPROVEMENT PERMIT LAYOUT ��'�'��y'1� �' �Jf�`�'`3� y' ��'�2� . s�,��,��i� � . ��� h��� . ����'' .; � ,� ����ju t� � � � � , �� � �� � � �� � �-,� , �-- - . �� � � �`L .�lf/ (�/,i�� '' . �� � � � , ,-- 1/ � ��n� �D`�� � � � . � P ! �1 : ,� � FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)'75I-8760. OPERATION PERMIT . SYSTEM INSTALLED BY: `. � � � � AUTHORIZATION NO. OPERATION PERMIT BY: DATE: *+THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE \ WITH ARTICLE 11 OF G.S.CHAP'TER 130A,SECTION.1900"$EWAGE 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. /OCHD 07AD2(Revised)� Qn A��'�Z/I�/ . .. � . . � . . .3 . .. . T�;c� '�6 S 7 T � .; �'.. l � �'qj' \ n t � A k d !,M1 9�� 1 )'r .� y . . +'1 ..N � ��.�� ���� ���' �/� 1 ���1 4 �,., } 1 1 1 �F Lfl t./ NO '� �,����DAVI� GOUNTX HEALTH DEPART�ENT� ,.� � y Y� ^,' �Env�ronmental Health SectionM PROPERTY I�IFORMATION �{ � ' ,.,� � , P O Box 848 f = � ' ` ` � . , - '; , , � , � �� ��.�� �"������� r Mocks'ville NC 27,.028 � Subdrviston Name„ � ` ` � � �,r � ' � � '�'� , ,�F j '' ' � � ` 'PhoNe# 336 751 $760 "' �„ � �� ��� , ;� � � , '� � toproperty ��""*fd!���'�" � �x t_� , x w ��.� a � � Sect�on � Lot � � � � �i �/ � ; � ' AUTHORI�ATION�FOR + � '� � _ - � i G��� !/,�/��G�?�� � ,�WASTE�VATER �� ; „ ; ' , � ` ' i S�'STEM CONSTRU�TION Tax Office PIN# r �, ' - S Y. ".i " n 1 , i : � / '. ( � A Jnl.r �� � - �� � ' ..�. � ��' . .: j . 1� / y�� I I ' 1 E k 1 � �: 7 ' q 4 I £� � t ' � � .� � ,,� +,�. ,� Road Name G!ll'/��� *fZip .�7d� ;' , � . f i � 3 1 ' . . �. . . �. ' ;" �, � � .�� .. ti t f � �'�t �: b F ,' y �4,> �. 1 � {i � i �.. .�. �,i � `. :. 1 .:,1 � S , ., �, i�**T'�ts putlionzaUon for Wastewater System ConStruct�or�MLTST BE I�S�,by ihe I)av�e County Envuonmental Health Secdon pnor. ; ' co i�'suance of�ny Building-Remute�-Th�s Fomi/Authonzat�on'Number shoWd'be presented to the Davie Counry Buili�ing`Inspections - ; � � ` 'Office,when apply�ng for Bu�ldtng Ferrnrts : � " � : ;� , � ` ;� '� £� � �; �;`r f ', ompl�ance with Articl� I 1 of C,S Chapter 130A WastewTa�er Systems Sect�bn 1900.Sewage Treatment and Dispo�al Systems)' �� < < " �2 n:y,.w s�� ` r� ,'��. G�i�ti �� :� � : ,t, .:i� a v � �, ,�fi';; ' �'�'�y".�' ""'" ��f'��� ��s ��� ^ + �; 'x r`;t �***1�OTICE***THIS ALITHpl�1ZATI0}�T��FOR WASTEWATETi GONS RUCTION+ �„ A�"��`""�� ,z E,��.��'s�'' .`'d �_ ' -,�'.`+"�,+"���'�"`� ! � ! t � �! � t� a � �-7 ' -� � , � � ��_� OR A R� �� ; � IS VAC:II3 F PERIOD OF FIVE YEA � �t� "ENVIRONMENTAL HEALTH SPEC.(ALIST ;� DAfiE ISSUED , � ` � j�,� - , ° � � � � � �� � � t , , 'n i � ,'� t a °>t � � .k-, ?\�����:.i ay # `� Fr a � � � S, �r»e. �.,{1 d i�:iil RESIDENTIAL SPECIFICATION BUILDING TYPE #BEDROQMS #BATHS 5 #OCCUPANTS�GARBAGE DISPOSAL"Yes or No�t ' `" r + " ` � � � � ��t �� �� �k a �� i � 3 t� �� Y ° a e,`t i 5;a � i ��''q ° ;�` " t 'J ,i; ' .: S i � ' �-, 'x a ; 1� •, ? : i :�. : '�r r �, i ': , "� � ��COMMEL�CIAL SPECIFICATION FACILTI'Y TYPE #PEOPLE #PEOPLE/SHIFF #SEATS INDUSTRIAL WASTE Yes or Not� M . } _ ,. ± ., x � �1 � �:: : ':a ��., '` i ;� � .�i a `'� � q c�.�:r ak � �*"+ u'{. .: ,_.; f ;, i. z /'';�'y� � ..: 1 p% ;�� � . ': � t :', t � �Y g -LOT SIZE 'LYPE WATER SUPPLY � `/ DESIGN WASTEWATER FLOW(GPD) �S�t'�I NEW SITE ' < REP.AIR SITE j ; � ` F, r� �i��/: js, 'i , ' SYSTEM�BPECIFICATIONS TANKSIZ�f�G� GAL, PUMPTANK, � GAL. TRENCH,WIDTH ROCKDEPTH LINEAR $ � r f i V % `-�w fi �i ,,F �amW� : y ` �� t'� W � � R ' OTHER � � - °1 ��z � , ;' ,- ;; ,' : ,c. ;� , � ' ,� � .'. ;RE UIRED SITE MODIFICATIONS/CONDITIONS �` Y 'r-' ' Q . ,� r:. ;e � i i � 1 t4 � `i � � � !1 �1 _ � ,d A t .� . �.� ,� y ��� ,..; � lt. I �! l d ����r i �i � .i.�it :��� � i � , , � y�:,, � � , �., i ..', . .� Y p, y.,. �, fF ' IMPROVEMENTPERMIr,LAYOUT :,�tp�VED EF�LI�W'M' FIL.TER� �FRISERfS? I�.6�' BEI.OW ;�'INI�'',,I'6E}7� .�"pR1�I}��'> ; � , �,; � ��- �� , � ,.; �� � - � , ;, � i ; � ` y � 4 .i� � � a ,� � � � � J eP.�' r i1,�, ��, d � � � �� o i �' e I 7 i ���x o }�� ,i r. r �,I y � A ?� 4` a ,ry,' r { � � i � � ��, n . „ ' , r ' � x 1 ( � �. . F i- � :. � . ' v t.f' t � r '.r'` r `� . t nr t { a f 4 � � � I �� . 1 V M ��� j � ' \ I ( � � d 1 � . 1 �k V i C �•�` t � . $ �`�i 1 t _ � � 3:4 ) C _ �I � '� f � . ' �� ! I F � I1 r.:. f { �� F l � '} �1 �� I .P � �' � � "� �d l � ,r: <' � a � � .. _: .. .. �:. . i _ � '. t '• — I. ..:, . . �. . .. � ... . . .,,. . '�: ° ': :' .. ; .: {. t ;_ **CONTACT A REPRESENTATIVE OFiTHE DAVIE COUNTl'HEALTH DEPARTMENT FOR.FINAL INSPEC'I'ION OF THIS SYSTEM ' ' ' � BE7'WEEN 8.30 9 30 A M OR.1 00 1i30 P M ON THE DAY OF INSTALLATION:'f�LEPHONE#IS('�OiK�4i�CA60Mt�i`.'�! � � . # f��� ` r o� .7�. � 1. I t ��� `�V���i�V��4' ��,� �:l ' �OPERATION PERMIT �= � ' r � `SYSTEIyi INSTALLED BY: '� � . G ` a' � �� s `� t ° ti. } v� � , , � ��, � �;t� t ���� , � � tit > � r , � �� ` } � ,, � :.i - Y �: ,'L � �j '„—" i ti! i � . � i + t �' � w . � . � � ' � ' � g `� ` i r s, �,� a a r! i re �� � x � � �d, r � �� ��, ,, � �n� 4 r s �. ,� � r J,. r� i .,� � � �1 �� r 1 1i �,�i 4 a �h¢�t � °i i� � 1� � _ �j��� ' �"' i;: a r a .w 1 r� p r- rr i � 5 � i, d � �'� I � � �� F 1 I ' '^'� ��� � 4 +��.3 �, `f N��� I Y � i l � a l , ..{ { a' � L/ r ,r"F, AUTHORIZATION NO � � �' °OPERATION PERMIT BY ' DATE: '/ i�� ��` r� ;. ,Y:, ' , ;;� .�.�,, ; : r', ; ; , � , , . ;; ; , ; = , , , ,z., , , . . . . .: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT TI-IE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE , , �;3 ; " ;WIT'H ARTICLEII,OF G;S.CHAPTER 130A;SECITON.1900`,`SEWAGE,TREAT�vIENT AND DISPOSAI:SYSTEMS';BUT SHALL IN NO WAY.BE TAKEN AS Aj d GUARANTEE THAT THESYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. . , ' �.� - �- , r r� � x "� �` �, i � yr °DCHD OS/96(Rev�sed) � t ,, ` � � a � �� '- ' > �.� ��8 � ,, .: , ' � ,� ,,, � �'; � ;� `4�,s,.,..u. ..,...w .,..�. _. ..,. � .� _.._. �..,,.. ,,,._u.�caw.� _,,. ,.,.ww ..,,.. .,. .w.,,,.��„,. ...,,r_ ,.c.rrc.� .�ti..�,..�, .t,�._ ...,r . ,.,�+... .�.,, .i., ,..�,....,_ ... �... ...� x_�_,W,., , .. ..,� ,,.�. � � � ��r�,�- 'D(o �► �k� � �b� � � DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION ��J .� , • �-tT1�{ APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) NAME i���� �%�`�'� PHONE NUMBER �� ��� ADDRESS �I 1 F�I��� � SUBDIVISION NAME �8�� LOT # DIRECTIONS TO SITE DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED _ TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING ��� �"1 ���-G�Y�►' DATE REQUESTED INFORMATION TAKEN BY This is to wrti(y that th�information provided is conoct to th�best of my knowledgs,and that I understand I am r�sponsibie for all charpes incurcsd from this applieation. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rw.1 J93 ,�a�.. ��n'" ����su�� "�...;��,�� �;?'��.'�`�� ��^4� �°� ."���� -�:�� ��`o*�Y��x��.''` �'; '�.� " a ��'. ° � , � .µ � ,. ' .. �. ., "-.� -m ,�.. �_ r�,$'� �'�a n�+".,'�.'.�. .� - *��„?���, 2 I . : �,. . �, , . c -� r � .�. .r � e..rG�� � . � ..�*i' . . . . . .. � � . . a r . .. 6 �yq� ..�.� .. a�� �.'�^ a°� '�:�q�r,�,�`��x*t„�''��„� �r R � � ° �.. ., d t: '�re��fl�,y���"� ��n�'��'@.?`"Y F�e��'ro` � �<�r..k � .:fi�'" .�° .°FL�.ey�' ^T �_a"r'r�� �� �Fy f ' . ���� Rr „.� ;'� I �� A .., , ���� .. .� � �i: *� h i,�' �re s $� " �r�a`'� �'� w ,.. I '- ^�� � � 1 � s _. . . � .� .. � . ' �. ., r � " o: F .. �u• � ` . _ . ,. , .., . . . �.� 4 e _ �. R � � - _ v� k�'� y °} ara �v ,. � �"ae.�' � .° � , " ��r�",�� ' q s s,,. � � s y, a � �. �'. r ^�. � .,..� ,... e .: r ` - s �° �� ,�*:.�: k ' ��w��'� � ..,�� ._�' �*�w�, �^ v,�. �,�s.. � "�� rc-ia � �s, �� .�d"3. 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