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1962 Milling Rd (2) ' � ►tiv W DAVIE COUNTY ENVIRONMENTAL HEALTH . �' ��� P.O.Box 848/210 Hospital Street �^ �� Mocksville,NC 27028 .�,, � P �,;Y� � , A (336)753-6780/Fax#(336)753-1680 ' PA , � V REPAIR OPERATION PERMIT p �°?% B`�:�� Account #: 990005763 Tax PIN/EH#: H600000024 Billed To: Ken McDaniel Subdivision Info: Address: 386 Howardtown Circle Location/Address: 1962 Millinq Road-27028 City: Mocksville Property Size: 42.13 Reference Name: Propos�y�F��#�y,;�1������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: � J S.T.Manufacturer_�� Date �l� Tank Size ��� Pump Tank Siz� i System Installed By: `�� �,�.��Clh�Q� E.H.Specialist: ate:�b`�7—�� GPS Coordinate: ' �� �� _ Cc��`�� ' � � ��� Dr��PtiG / / -- � � � S ��_ � � , � � � '/ /'a�� � ' �, � � , . 1 �,\ ' '�CC K i ve , ! � �� - .__ __� __ / � � �j J/ ' �a ' . . �.^"'i j��.�_� _� ��._ ��r� � �t�ver.va� — � -�s, �. sr �� ��v ��' % ��s��r�� �� o , ��� � �� � ,�ay,, , � . � 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 Acct�ur�t �: 990005763 �'�x F�I�:EH#: H600000024 Bille:� To: Ken McDaniel Su�adivi�iar� 1���: Refer�E�ce �lar���: : LocaiionJAd+�r�ss; 1962 Milling Road-27028 ` Propc�se� Fa�:i€ity: deck/cabana .. . Pc���rty S�iz�: 42.13 Site Type: ❑New ��pair L��xpansion ATC t��a�tb�r: 5829 **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 VAL�D FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if�ite plans,plat , or the intended use change. � Residential Specifications: #Bedrooms�#Bathrooms #People Basement❑ Basement plumbing❑ Non-Residential Specificatious: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size � �' ' � Type of Water Suppiy: ❑County/City OWell ❑Community Well _��x�5����0��GAL.Pum`p Tarilc GAL. System Specifications: Design Wastewater Flow(GPD) �d Tank Size �, �� �� �� Q � Trench Width ��e Max.Trench Depth 3 �O Rock Depth � a Linear Ft.� ,,:: . : i;� �.:- _, �•-� Site Modifications/Conditions/Other: E ':• , � : ` " ' ' ` ` ,' `�{ ''` Contact the Davie County Environmental Health Section for final inspection of this system between 8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760. . � � �tY ,�-�G� �C�h� .'• .\\�`v�,� �s��`,�' �' �lK�rJ D� d � � - �"i , ., '� � 01 r � ,� \ `�a � vv� � � �1 �. ? 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L�tJ� � ,'.-���. 1� ��,�r,�cT �/ ����� � ,� _ � _ � � M ~ � �` WdD� �� �. �� � � � �� � > > Ji i ( . � � I � � �ti�� �—x���• � ' �d�`.� �do�. a ���� ��s`�-• ���� � uu� — _ . � ������ � �� � j �►S�c, �,�11 �� CT�C01,1� (,�'�-C�V�. j -- . ���r � ����� r �sr�� 1 l _. �. � _ _ � �4���. . . ��:_.---�. �. �a�e��'� � Uo � vazy C-(� Da�ie County Health Department : . �pI836j� Environmental Health Section ��Y ' . ;. , . �� � '� P.O. Box 848 � � • �. � ,�''��„ 210 Hospital Street �����1 • � O U �.'� Courier# : 09-40-06 r�lpCG-��' 1911 Mocksville, NC 27028 � Phone:(336)-753-6780 Fax:(336)-753-1680 (Check One) Replacement Remodeling Reconnection Name: ; �—t� �'ICf,�! ll�l�� Phone Number�>�r !�� `��1) ( (Home) MailingAddress: �G, � ITu�Nti'1��6V�1, C'I�..C���. (Work) �1G�f~����11 GF�N� Z-�GZ-I EmailAddress:__�`�--��"�,r'�c�7�-����'��. � 1�/�r/�1�1�i, Detailed Directions To Site: 'S(S `�r0 �i U[�/N � � �U�� �.� C'��� • �G�� f��`�r? /`"r�tl �-� � (a L�1�t ���� Y� I��f�-1� �f� [,ti'�(f��/�� � ��l t�tfi ~� t1�vJ�� T � �� � �-� �� �.� fT Property Address: �� � 7..- 4���L �� �� � ' Please Fill In The Following Information About The EXISTING Facility: ` '�.�I a �� Name System Installed Under: u4�`�` ��C' ��� ti ►`���� Type Of Facility: � t�� _ Date System Installed(Month/Date/Year): ��`( Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? Yes No If Yes,For How Long? ��-- Any Known Problems? Yes (� No� If Yes,Explain: Please Fill In The Following Information About�'he NEW Facility: � Type Of Facility: C-G�T'��'� ���� ���� 1 I�N, Number Of Bedrooms: Number of People Pool Size: arage Size: Other: ZG �-�' � � Z�� �' ' � Requested By: ����� � , Date Requested: (Signature) For Environmental Health Office Use Only E A _prDved Disapproved ;. � ,e-_ � Comments: ,l'�•�'P „/ � Ci i rrl � �-:�.=-3 r l'J�.';- ;;r :,9.� -, r" �,� � r' �' �-r'�:='' 't {' f �/ _ ! �� /' F�^ � . Environmental Health Specialist �_..,�� ' �`'`i;�:°f>�°i,r`'�..✓�� ��� Date: i—/.? - ,// r�,,. *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 far any given period of time. Payment: Cash Check Money Order # Amount:$ Date: Paid By: Received By: Account#: ��(�b� � /�a3 Invoice#: � �� �+� �C41L� n N ��� a � - �� � - , �'£� �`�a� � cc ��Z � . . �, ��� �� � � d� �, � � �1.. O��S ;' , ` I c�'� , (R�'�1 , ` �� �-� 5�(� l �u-� S� �''� � ' ,. `�� 5� �' �� �� � � ��M �� �� . ,�,� � � 5� , _ , ,, � . . ;- . , � '.':J't�.. ' .�� ' � � "� .f '_'�;. . . . .� ♦ rJ � .�.er�,r...�J � �+w�+�f _ , � .'="`�` Davie County Health Department . �� ��►8 j�s � Environmental Health Section � `,� .- , �� : "`� P.O. Box 848 . � C� l '' �"��, 210 Hospital Street ' O U �'� Courier# : 09-40-06 1911 Mocksville, NC 27028 � Phone:(336)-753-6780 ON-SITE WASTEWATER CERTIFICATION Fax:(336)-753-1680 y (Check One) Replacement Remodeling Reconnection Name: �r ��1td C.U�-Y Phone Number ���� "- �f��`0 J � (Home) Mailing Address: �'�"",�'°"`:� /'� ) N•�i h> �r `_, (Work) Email Address: � . Detailed D'uections.To Site: �'F�� �"I'1�L�-1 �'U� r` `� � ��-S� ��S r T7�r �-��' �J...� p..�,T.'. ���-- �4�c � ��'� �c.-:� ( ,�'�" • �, �, Property Address: � '� ;(71 1 1 J ! �J� ; � �}Y�jt�1r,..� {,J 1..�.-�� s 54. Please Fill In The Following Information�bout The EXISTING Facility: Name System Installed Under: �..J� =>/�I�l�J � Type Of Facility: 1 �'��-� /�/�`, ;. Date System Installed(Month/Date/Year): �`%�'1� "��� Number Of Bedrooms:_�Number Of People: �� Is The Facility Currently Vacant? Yesf,yl�id if Yes;F��-0How Long? Any Known Problems? Yes �� If Yes,Explain: Please Fill In The Following Inform„a.�tfon About The NEW Facility: ��� Type Of Facility: W � �� � Q��"'� Number Of Bedrooms: Number of People Pool Size: ��x '1 � �arage Size: Other: � Requested By`.` Date Requested: � Signature) , _.-�-- For Environmental Health Office Use Only �`Approved Disapproved � Comments: ��� ,7 1;r ,% {` �;�')r� y'' f f; r � /r�; � .• :�`J� C°. ' `.'�y �..� � -t".c'.c..�-t � �I --�� � � .A.• ✓!' +� .P 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 guarantee (extended or limited)that the on-site wastewater system will function properly for any given period of time. :.�---•., � . Payment: Cash, Check Money Order # �' Amount:$�'t�f ��� Date: /,1 �` f� -" � "_ �• � � --- Paid By: , {���/�.t �,; ( Received By: � ��,�Pt//�;,✓ Account#: tj��J� �� � Invoice#: ��l fG� � � _ . .� . ._ - - - - _.- . :Y;� .���:;� a :;-�.., �� � � '- ' k �� � � � � � 4��'',� . � I r f��' y/�.�- � • �``> ' f.��') ' �• ��"��g �"�� � ;W � DA�'IE COUI�T1( NEAL'�M DEPARVRlB�N7' 4� � � h 'x) w;�: ' � � ' � ' IRlIPROVEIUIENTS PERMIT AIdD CERYIFICAT� O� �0���,����� 2 I •NOTE:issued in Compliance With Article I I of G.S.Chapter 130a � Sanitary Sewage Systems � �y`. P�rs�s� P�aamber I Name +� �n/�/ Qr / r� 'f�! 7��•� ,r' �/�,;�ir �8�8 �,/ .c �/,�;i.ir, �� � ` � � ��° � � Locat n a"i :/' ,, J'�f�� ",��`--.�`�y" � ,1 =.,,�� , �^ I ... -.r.° — �,y� ��,1 J!'., /��: �'"� !7J �f��'r"��_� �� � � ' . i•'� !J �l ; I Subdivision Name Lot No. Sec. or Block No. - i � I Lot Size �,.�`'_�'%<" House � Mobile Home _T Business _� Industy � ; ' No. Bedrooms "`� .No. Baths �-? — No. in Family �f _ PublicAssembly Othor ; Garbage Disposal YES ❑ NO p� Specifications for System: Auto Dish Washer YES , NO ❑ �r� �,�,.��� ,�" ,�,a-;::�:S �. (��.. � j Auto Wash Ma^hine YES NO 0 -� I '� TYPe Water Supply — --- `��+��'„}'-� ,,�'.✓�> � - i � 'This permit Void if sewage system described below is not 'nstall d ithin 5 years from date of issue. This permit is subject to revocation if site plans or the inte d d s change. � �.y..�y � ,,.,,.......�,•��p . - � � �, �: �,�...,.,.....,._,,,..,....A � �• � � il Improvements permit by —��_' J�'— "Contact a representative of the Davie County Health Department for final inspection of this system between f3:30-�:3�A.M., 1:00-1:30 P.M.or 4:30-5:00 P.M.on day of completion.Telephone Number:704-634-5985. Final Installation Diagram: System Installed by _��`�'�'"-'�'w �-�-¢^��-�-� - �`-� � —___-------~."..._..._...__---f c !J..;�, `' � ��, � � ._..�.____�_,_"'_._.,� �—� i ' � j'�d ' �-�. � 4"_� �v.,� r, ., ,}� ; � ..� . , , , ,; ,_._. ,_ ..:�. __.__.._ i,, Y ...�..,. . . rA �. +_.�n.., " ; ; ` j� .,.. . . . �.1 R j : . % f l ._..... ............._.._._._...�._'..._._.,l ; P A , j ` '--:..,__�__�.._.. �.x . .: i ...,_.. . _.,.c. , , ;- r_ - -__.. .__ . , , , - ' }: ; ,. _. _ �__..... r• , . , ,,..:.._ ___._ .__.� .._ ; r � ,., ..... ,�}. _ .. � ;t�, r . o • ... ,,,,._ � _ , e ':—_.,_ ____....�_..__------ ` " .� Certificate of Completion-':: -____ =:� ` ,-�i�, �at@ �� � � ����� "�� 'The signing of this certificate shall indicate that the system described above has been installed i� compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee th�t the svstem w�ii f��►,�t�.,� c7ticfonfnril��fnrn.,....:....� _--'--+ _�.•..