110 Cameron Court Lot B0
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Account #:
9 000060151,
Billed To:
Reference Name:
REPAIR PERMIT
Proposed Facility-
Residential Repair
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680
REPAIR OPERATION PERMIT
Tax PINIEH #: E8020B0002 '
Subdivision Info: Raintree Lot # B
LocaiioniAddress: 110 Cameron Court -27006
Property Size: 1 Ac
ATC*l IMW.f T&02&uance 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: .J�► / S. Manufacturer e , Tank Date Tank Size
Pump Tank Size ' Bedrooms 3
System Installed By: TA� e_ 2 r`n P_f Installer#: Date: SLY
GPS Coordinate:
i
DCHD 11/06 (Revised)
i
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 #: 990006015 Tax PINiEH #: E8020B0002
Billed To: Dillon Thomas Subdivision Info: Raintree Lot # B
Reference Name: REPAIR PERMIT LocationiAddress: 110 Cameron Court -27006
Proposed Facility: Residential Repair Property Size: 1 Ac
Site Type: ONew Repair OExpansion
ATC Number: 6028
**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 chance.
Residential Specifications: # Bedrooms # Bathrooms—21— People BasementO Basement plumbingO
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size i L Type of Water Supply: ❑County/City OWell DCommunity Well
System Specifications: Design Wastewater Flow (GPD) _3 t;&_Tank Size E?&*L. Pump Tank ,"GAL.
Trench Width �. Max.. Trench Depth_( Rock Depth Linear Ft. Me 2S%
Site Modifications/Conditions/Other:
Contact the Davie County Environmental He6ith 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
DC'HD 11/06 (Revised)
.�` DAVI COUNTY ENVIRONMENTAL HEALTH ERVICE REQUEST i4
3-7 "` ,_ APPLICATION IP/ATC OSWW REPAIR
Name � .�1�161U �10�Y1�1s
Addriiss
Mailing Address (if different from above) _
Email Address: Ul .S'
Subdivision Name Aal
Directions
�S i SPP/G•
Telephone Number
Lot #
Date System Installed { Name System Installed Under
Type Facility Number Bedrooms Number People Served
Type Wat r Supply_ Specific Problem Occurring kola -1-1/-11
a tli% 1 I-Z�3
Date Requested' f % Info Taken By /
THIS IS TUgERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY E
KNOWLEDGE, AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED
FROM THIS APPLICATION.
Signature of owner or Authorized Agent F.
Initial Fee Date REHS
Revisit Charge Date Reason
Revised 2-201-
DAVI COUNTY ENVIRONMENTAL HEALTH ERVICE REQUEST
/ APPLICATION IP/ATC OSWW REPAIR
Name �/I U�� �1 S Telephone Number ��' �Q3 0
Address
Mailing Address (i different from above)
Email Address:
Subdivision Name Lot #
Directions X-9-1-1119JW01616
reek, e-
Date System Installed Name System Installed Under
Type Facility Number Bedrooms Number People Served
Type Water Supply Specific Problem Occurring �jT4 /,=/4 f /
-0
Date Requested 1 Info Taken By C1
THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY
KNOWLEDGE, AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED
FROM THIS APPLICATION.
Signature of owner or Authorized Agent
Initial Fee Date REHS
Revisit Charge Date Reason
Revised 2-
L.,Vf IILUIG 5
DAVIE COUNTY HEALTH DEPARTMENT
- IMPROVEMENTS PERMIT AND -CERTIFICATE OF, COMPLETION
'NOTE: Issued in Compliance with. G.S. of North Carolina Chapter 130 Article 13c
Sewage.Treatment avid Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name l2AN�, S,SeI`.13w; I�r�>/!� te_C'lr�n��c Date (.- -8'3 �0� 301
�,,....�
/2.9 .
Location Ro I. Q,iu�cr' ItQ!'hLP-!Q
Subdivision Name ?u; r,TZt-' r zdd: Lot No. t3 Sec. or Block No. '
Lot. Size �J� ca c. House_ '-� Mobile Home Business Speculation
No. Bedrooms 3 No. Baths i VL No. in Family 3
Garbage Disposal YES [-� NO ❑ Specifications for System: �,A- 7f''U'�
Auto Dish Washer YES, p' NO ❑
Auto Wash Machine YES • [l NO C❑
Type Water Supply T --
*This 'permit Void. if sewage system described below is not installed within 36 months from date of issue.
Improvements permit by
'Contact a representative of the. Davie County Health Department for final inspection of this system between 8:30-
A -.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by
1 b
Certificate of Com letion �^^ �°
p Date -43
'The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
.too l�
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone '"02 C - (" a-
1. Permit Request By S„•S'e Cosox D`• Business Phone
2. Address D a1. ��� - G o� ✓,Q.�ce %V - c, A,7 mG 6
3. Property Owner if Different than Above SAAI e, Av' A -4&•r Aea • %pl /�di
Amoss .'!� a ^- d S s y e S n� neo •w l e�o�d I u� �9� e, G e e!c v vW
4. Permit To: a) Install Alter Repair 1°/v.iei C,'L'700
b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division /1 0/-' - e- Sec. Add Lot No.
5. System used to serve what type facility: House s-' Mobile Home Business
IndustryOther
b) Number of people -3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions a k x y0
Bed Rooms_ Bath Rooms off- 2d- Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water -using fixtures:
commodes •3 ” urinals
4/" / q dyA I — l�`'O r
lavatory "Zfew��arl
dishwasher
sinks / —• / X 3';
garbage disposal ✓tS
washing machine ytt
8. a) Type water supply: Public A--� Private Community
b) Has the water supply system been approved? Yes I-' No
9. a) Property Dimensions Sec 014-r ' h/y
0.1
b) Land area designated to building site ��ad
c) Sewage Disposal Contractor 7�14 TTL
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? No
What type? -SW 111'c 7-A w % i ra 4•0 410! � Id'oX 1, /1 1 ;U el
This is to certify that the information is correct to the best of my knowledge.
e� Z4j,- Ar
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to p
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DCHD (6-82)