190 Swicegood St Lots 41-44D'AVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street.
Mocksville; NC 27028
(336)753.6780 / Fax # (336)753-1680
REPAIR IMPROVEMENT PERMIT
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account M 989900024 i ax PIN/EH #: M510000005
Billed To: Roger Spillman Subdivision Info:,:,
Reference Name: REPAIR PERMIT Location/Addte'ss:.190 Swicegood St. -27014
Proposed Facility: Residential Repair Properf. Size' 0':35 Acre
Si e Type: Repair U9 Expansion ( )
ATC Number: 5887
"NOTE" This IP/ 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 IP/ 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 chanee.
Residential Specifications: # Bedr6oms2 # Bathrooms I # People 2 BasementO Basement plumbingO
Non -Residential Specifications: Facility Type # People_ # Seats_
Square Footage(or Dimensions of Facility)
LotSize Type of Water Supply: ❑Co/u`nty/City OWell .0Community Well..
System Specifications: F Design Wastewater Flow (GPD) iq V Tank Size AL. Pump Tank GAL.
P P� ��
Trench Width � Max. Trench Depth Rock De th2 Linear Ft.
Site Modifications/Conditions/Other:
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)753-6780.
LA
DCHD 11106 (Revised)
J9i
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780/Fax #(336)753-1680
Account #:
989900024
Billed To:
Roger Spillman
Reference Name:
REPAIR PERMIT
Proposed Facility:
Residential Repair
ATC Number: 5887
REPAIR OPERATION PERMIT
Tax PIN!EH #: M510000005
Subdivision Info:
Location/Address: 190 Swicegood St. -27014
Property Size: 0!35 Acre
**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.
System Type: S.T. Manufacturer Tank Date Tank Size
Pump Tank Size
System Installed
GPS
DCHD 11/06 (Revised)
E.H. Specialist: Date:
f 11. 40, PO 0'7(
DIRECTIONS TO
PDAP rvy/.PA a
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
PHONE NUMBER' pZ25f'
SUBDIVISION NAME' d G�
LOT #
DATE SYSTEM INSTALLED lq&O (S NAME SYSTEM INSTALLED UNDER �W�`l/YLH4)
TYPE FACILITY�_NUMBER BEDROOMS c NUMBER PEOPLE SERVED
✓;
DATE REQUESTED INFORMATION TAKEN BY
This is to oertlfy that the Information provided is cerreot to the best of my knowledge, and that 1 understand I am responsible for all chargee incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT,
Rev. 1193
GoMAPS - Davie County NC Public Access
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•"WARNINU:'1'H1S 1S N01' A SURVEY!"" Wednesday, March 7 2012
This map is prepared for the inventory of real property found within this jurisdiction, and is compiled from recorded
deeds, plats, and other public records and data. Users of this map are hereby notified that the aforementioned public
primary information sources should be consulted for verification of the information contained on this map. The
County and mapping company assume no legal responsibility for the information contained on this map.
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