188 Baltimore Trails Lane Lot 1•
Account #: 990004262
Billed To: Brian Monk
Reference Name:
Proposed Facility: Residence
ATC Number: 4624
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 Fax # (336)751-8786
OPERATION PERMIT
Tax PIN/EH #: 5860-54-9241
Subdivision Info: 14--1W1
Location/Address: Baltimore Trails -27006
Property Size: 14.64 acres
**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 shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of
time.
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System e:S.T. Manufacturer �' Tank Datetl-t' wk Sizel z OQ
Pump Tank Size _
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System Installed By: f c ���c^"� "`��E.H. Specialist:Rk\t'-�&Vacute:
DCHD 11/06 (Revised)
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DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 Fax # (336)751-8786
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990004262
Billed To: Brian Monk
Reference Name:
Proposed Facility: Residence
ATC Number: 4624
Tax PIN/EH #:
5860-54-9241
Subdivision Info:
$3P I� �Vt't01� ��C'ctI 5 L0l
Location/Address:
Baltimore Trails -27006
Property Size:
14.64 acres
Site Type: ❑New ❑Repair ❑Expansion
**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 --1— # Bathrooms 3 7 # People Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats–
Square Footage(or Dimensions of Facility)
Lot Size Type of Water Supply: ❑County/City ffVVell ❑Community Well
System Specifications: Design Wastewater Flow (GPD) ��d Tank Size_,(o� GAL. Pump Tank GAL.
Trench Width Max. Trench Depth Rock Depth f 7: �Linear Ft.
As stated in 15A NCAC 3_SA.1969(5�
Site Modifications/Conditions/Other: accepted Systems ma afro h-- us
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30 – 9:30a.m. on the day of installation. Telephone # (336)751-8760.
Environmental Health Specialist
DCHD 11/06 (Revised)
16-0-'7
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C TI SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760/ Fax (33 )751-8786
� `ENjA�NEAu�
Ap lication �R jt& on/Improvement Permit Authorization To Construct(ATC) ❑ Both
Typ of A ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed7J) 1,1 1b KI Contact Person k Cc tJ
Billing Address Home Phone Z Z - 7— 's I
City/State/ZIP S c? - I Business Phone co q-
71C'(J.
Name on Permit/ATC if Different than Above
Mailing Address
PROPERTY INFORMATION *Date House/Facility Corners Flagged e<; o? o?lr V
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
(Permit is valid for 60 months with site plan, no expiration with complete plat.)
Owner's Name3, 5.-1a o C. M o a:, I C- Phone Number C G Z-
Owner's Address (? i l —,4 1 U t'-'F-T('_C_. t City/State/Zip4QC.,1 D t
Property Address -PSC- 4-in-)6CL--CtA, Is City klk-4 Q CL -
Lot Size Tax PIN#
Subdivision Name(if applicable-TQ4 i I e,, Section/Lot#
Directions To Site: A 14,rnc�i r' mil -iu i� f %ern o� �nl%YJ I i k C ' 1-01a,
—L)1; VA 6 1-1- OU 1 A t`i 1Lj- TS Ll' -
If the answer to any of the following questions is "yes", supportidocumentation must be attached.
Are there any existing wastewater systems on the site? Dyes PNo
Does the site contain jurisdictional wetlands? Dyes C(No
Are there any easements or right-of-ways on the site? KYes ❑No
Is the site subject to approval by another public agency? ❑Yes 15INo
Will wastewater othei than domestic sewage be generated? Dyes RNo
IF RESIDE CE FILL OUT THE BOX BELOW
# People 4 # Bedrooms L4 # Bathrooms 2- Garden Tub/Whirlpool i Yes ❑No
Basement: Dyes )No Basement Plumbing: ❑YesNo
IF NON -RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business Total Square Footage of Building # People
# Sinks # Commodes # Showers # Urinals
Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: # Seats
Type system requested:. Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: ❑ County/City Water L/ Tew Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes
If yes, what type?
E.
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that
any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if
the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative
of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules.
I unde hand that I am res onsible for the proper identification and labeling of property lines and corners and locating and flagging
or stak ng th/eh�ouse/facil' location, proposed well location and the location of any other amenities.
Site Revisit Charge
Property owner's or owner's legal representative signature
Date(s):
aClient Notification Date:
Date EHS:
Sign given Dyes ❑No
Revised 11/06
Account # Z, & Z
Invoice # Q