1485 Underpass Road Lot 16DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680
REPAIR OPERATION PERMIT
Account #:
990005855
Tax PIDiEH #:
E811000001
Billed To:
Roy Adams
Subdivision Info:
Westridge Lot # 16
Reference Dame:
REPAIR PERMIT
LocationiAddress:
1485 Underpass Road -27006
Proposed Facility:
Residential Repair
Property Size:
0.63 Acres
ATC Dumber: 5914
**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.
d
System Type: S.T. Manufacturer �h �P Tank Date IF �f Tank Size R- ` ✓/ "�
Pump Tank Size Bedrooms_ ,, /
System Installed By: f ct.� svk- Inspector -4- ^//// Date:
GPS Coordinate:
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715 Cil
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Environmental Health Specialist:
DCHD 11/06 (Revised)
Date:
T,vueiee-j4t "41 ZZ
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 #: 990005855 Tax PIN,EH #: E811000001
Billed To: Roy Adams Subdivision Info: Westridge Lot # 16
Reference Name: REPAIR PERMIT Location"rAddress:; 1485 Underpass Road -27006
Proposed Facility: Residential Repair Property Size.` 0.63 Acres
g 4 Site Type: ❑New (.Repair ❑Expansion
��T*� rThisAuthorization 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 # Bathrooms # People 3 Basement❑ Basement plumbing
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size r'C Type of Water Supply: ❑County/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow (GPD) I( LTank SizeLkaGAL. Pump Tank GAL.
Trench Width Max. Trench DepthRock Depth/)/fi_ Linear Ft. O--1 d�%O
Site Modifications/Conditions/Other:
Contact the Davie County Environmental Heilth Section for final inspection of this system between
8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760.
4f bkm e, k*
001 Csrea
Environmental Health Specialist
DCHD 11/06 (Revised)
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tte: �7aDI Z
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DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST
APPLICATION IP/ATC OSWW REPAIR (.� `% 3A 687----IN91
Name PM1,1vat45
Telephone Number 3j(p g��rS�L2
Address dOM55
kd, [J"d& AI& 2 W
Mailing Address (if different from above
Email Address:
Subdivision Name
Lot #
Directions
�75 ' D . ,
Date System Installed `7 %
Name System Installed Under 6i%U-Z!0
Type Facility
Number Bedrooms Number People Serve
Type Water Supply &UltkV 7
Specific Problem OP urringDumD
Ont) 1AJAU no" % I V
&4 OIL/4A11K
D4 Requested
Info Taken By
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 2-2011
DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C)
OWNER OR 'CONTRACTOR f ;,.:"',"' e'r' DATE. J. / 7 J PERMIT
N°
LOCATION (I,1.4 rs:�'r�+'�,; �'c'. 361
S.R. NO.
SUBDIVISION NAME ,tJf�ti r �c f— LOT NO. 1(^ SECTION OR BLOCK NO.
HOUSE IBJ MOBILE HOME ❑ BUSINESS
NO. BEDROOMS -� NO. BATHROOMS - �;-
GARBAGE DISPOSAL UNIT YES Qr NO ❑
AUTO. DISHWASHER YES (M NO ❑
AUTO. WASH. MACHINE YES Q[- NO ❑
SITE SUITABLE YES P!-' NO ❑
SIZE OF TANK 1'..7 �TQ gal.
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ❑ Public ❑
IMPROVEMENTS PERMIT BY 4
CERTIFICATE OF
---------- By—
(8/16/73) *Construction must c
LOT AREA
House Trailer 800 Gal. 400 Sq. Ft.
Two Bedroom House 800 Gal. 600 Sq. Ft.
Three Bedroom House 900 Gal. 900 Sq. Ft.
Four Bedroom House 1000 Gal. 1200 Sq. Ft.
lok
INSTALLED BY
Ma.,,h Date -7-2r-17
with all other applicable State and local regulations
E
IQ
it � -.{•
..44t
lb
i
eA--
DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C)
OWNER OR CONTRACTOR' -� (� DATE _, !" _ -,,-. PERMIT
LOCATION j , .a. l/ �" •E' f> •-� r. I N9 928
S.R. NO.
SUBDIVISION NAME LOT NO. J j�SECTION OR BLOCK NO.
HOUSE ❑/' MOBILE HOME BUSINESS ❑
NO. BEDROOMS 7. NO. BATHROOMS
GARBAGE DISPOSAL UNIT YES ❑ NO Cjl.
AUTO. DISHWASHER YES []/ NO ❑
AUTO. WASH. MACHINE YES Q, NO ❑
SITE SUITABLE YES [[;I.., --NO ❑
SIZE OF TANK 64,)1:2 gal.
NITRIFICATION FIELD 0;'L':7�.;,,sq. ft.
DEPTH OF STONE IN LINES:�,e�
WATER SUPPLY: Individual, / 0. --Public ❑
IMPROVEMENTS PERMIT BY kt,-j
House Trailer
800
Gal.
400
Sq.
Ft.
Two Bedroom House
800
Gal.
600
Sq.
Ft.
Three Bedroom House
900
Gal.
900
Sq.
Ft.
Four Bedroom House
1000
Gal.
1200
Sq.
Ft.
7 �l/ ? 7 - ?,eln 5I_rz P -,e—; /_ -A o s
INSTALLED BY
CERTIFICATE OF COMPLETION
By Date
(8/16/73) *Construction must comply with all other applicable State and local regulations
LOT AREA
`4L too x
40DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C)
OWNER OR CONTRACTOR ', eJ .i / E •-i �„ DATE �+- �� /r PERMIT
LOCATION N9 928
. � S S.R. NO.
SUBDIVISION NAME , ✓� �_/� LOT NO. SECTION OR BLOCK NO.
HOUSE Q.r-'` MOBILE HOME BUSINESS ❑
NO. BEDROOMS 7_ NO. BATHROOMS 'L,
GARBAGE DISPOSAL UNIT YES ❑ NO 0
AUTO. DISHWASHER YES NO ❑
AUTO. WASH. MACHINE YES ❑ NO ❑
SITE SUITABLE YES,- NO ❑
SIZE OF TANK i `" %"" gal.
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual 3, --Public ❑
IMPROVEMENTS PERMIT BY (..-[
'"j � 4q—&— /C^--4. i
CERTIFI
(8/16/73)
LOT AREA
House Trailer
800
Gal.
400
Sq.
Ft.
Two Bedroom House
800
Gal.
600
Sq.
Ft.
Three Bedroom House
900
Gal.
900
Sq.
Ft.
Four Bedroom House
1000
Gal.
1200
Sq.
Ft.
If/ 7 7--M44.51ex Ae—: t f o s
,14,«y t% 1f /O %ite_. 74
INSTALLED BY
OF COMPLETION
BY Date
*Construction must comply with all other applicable State and local regulations