115 Pepperstone Place Lot 27 ,� ,�+ , ,. r�• .�ry,�,."�i t'Y"'r' ,#,.9`C � �,.;.y, t -.t-s. ,�. ., .. `t' i '-- - ,.; _
' 12
AUTHORI?�,ATION NO: ', a DAVIE COUNTY HEALTH DEPARTMENT .
Environmental Health Section PROPERTY INFORMATION
Permittee's* P.O.Box 848 p
Name:' =171--I Din0 16A)a�- None Mocicsville,NC 27028 Subdivision Name: f�l: �a
Phone#:704-634-8760 2�
Directions to property: tjt�b V I r -1 0 Section: Lot:
AUTHORIZATION FOR
WASTEWATER
N JU Wil) d►T SYSTEM CONSTRUCTION Tax Office PIN:# �V
b Road Name: 15C.Zip: UZ
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits.This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with
Article 11 of G,S`Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
/' ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
.: ..- f +— Z IS VALID FOR A PERIOD OF FIVE YEARS.
ENI �NV R MENT HEALTH SPECI S DATE SS D
r
COUNTY HEALTH DEPARTMENT
a IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittee'; �{ ;
Name, .9 l d In 6 '1!F4Subdivision Name: >✓ft l-fR5syor 4
' Directions to property: l�' t:'L i i Section: Lot:
DAPROVEMENT
i'0 1 G.n) l� ; 1.i PERMIT Tax Office PIN:# r° U - 7<
fir+ t !=' j s flrJL(tL ( ,-A r,,.} (.t-J
Road Name: � T� ro �. Zip:�•�
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S..Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
j
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
`•�_� . ' _ ; . y L_ ._•- ' y PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DA� SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
.. INSTALLING THE SYSTEM. `
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS 0,#OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILTTYTYPEE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE JoDXZ')O TYPE WATER SUPPLY CD DESIGN WASTEWATER FLOW(GPD) DO NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE [��� GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH Z f t LINEAR FT. i
OTHER I 019F—i 7OT1a^3 UfJ)C
REQUIRED SITE MODIFICATIONS/CONDMONS: TAILf�A �(J(�'fptJrL r ��1.tf S' f F sC.I4�{=r ")Fr PQytt'QIV
t_t►J�
IMPROVEMENT PERMIT LAYOUT
,j
Most _
n n
F P crJT
^ti
P
"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(704)634-8760.
OPERATION PERMIT +�D /�/✓ W
INSTALLED Y.
L 40
�
z� ,
3
15
AUTHORIZATION NO. �"�02� OPERATION PERMIT BY: DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDIC 9THAT THE SYSTEM DESCRIBED ABOVE 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.
DCHD 05/96(Revised)
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT&ATC
L2 Davie County Health Department 0 d R
�a 1 Environmental Health Section
� i b P.O. Box 848 ' 3
1" �j INF V Mocksville,NC 27028 FEB IMM
(704) 634-8760 it
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSE
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed—�l/f�J D142 Contact Person
Mailing Address R 6� / Home Phone
City/State/Zip t -! 70 Business Phone '�-
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: [ Site Evaluation [ ]Improvement Permit&ATC ( ]Both
4. System to Serve: [14House [ ]Mobile Home [ ]Business [ ]Industry [ ]Other
5. If Residence: #People #Bedrooms #Bathrooms_ [{Dishwasher[ ]Garbage Disposal
[Washing Machine [ ]Basement/Plumbing [ ]Basement/No Plumbing
6. If Business/Other:Specify type #People #Sinks #Commodes
—
#Showers #Urinals #Water Coolers
If Foodservice:#Seats Estimated Water Usage(gallons per day)
7. Type of water supply: (/rcounty/City [ ]Well [ ]Community /
8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes [ JY No
If yes,what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED:***IMPORTANT***)XFLW OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: Z66 Z j�34 WRITE DIRECTIONS(from Mocksville)TO PROPERTY:
Tax Office PIN: # 5,5,12 D
Property Address: Road game &J Y i Ah h r 14e- 1'ak t V10 h�! /�dL fit+ 1� joy
City/Zip ; 1 -4 edhIt e 0 12 T
If in Subdivision provide information,as follows: `e l' �d L /11 y- //2 e
Name:
QSection: Lot#• '
This is to certify that the information provided is correct to the best of my knowledge.I understand that any permit(s)issued hereafter are
subject to suspension or revocation,if the site plans or intended use change,or if the information submitted in this application is falsified or
changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized
Representative of the Davie County Health /De artment to enter upon above described property located in Davie County and owned
o c duct all testin roced as necessary to determine the site suitability.
nn
DATErL '— �o� ' NATURE
Revised DCHD(06-96)
THIS AREA X(AJ $E USED FOR DRAWINC7 JOUR SITE PLAN:
{ 2Z
IL
7Z
SO
K�
LOT CURVE
12C12
26 C13
25 C14
CLNTERLIN ruRVF pATe 24 cis
CURVE ♦ 3 CURVE ; 4 24 C16
A a 14.45'09" O 16.30'48" 23 C17
R • 347.63' R - 689.13' 22 cis
T • 48.00' T • 100.00' 21 cis
_
19 C22
L •
88.90' L 188.61' 20 C2
20 C211
Z.$br 28 C23
27 C2
34. S 82 4
78'07* Z° WA C24
15' Utifify L` � — 1 2p0.30+ 27 C26
o0 C25 3 6\
3 70 k 70 `� �' Cx g0 SIG►I �? �7'00h PAUL_ r Hc►�DRI KS
SCh y, 50CGo•m�1 686, C• TAX LOT 9 3.01 MAP F-3
° 10 x 10 St= 77�78� DECD ROOK 162 PAGE 016
/cv C14 28
� c� 4 9?,
0
N 1t 0 152.3s,
o„ w 16.7 s Z -�,-. 1
s 78 - v
05 w o
270 1 m ml }m Z Z8,
�1� , N 7941`29 a °o
0 0 29 ` n ` 232.41 Z °' O
2 O f>
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° 5
74009`39" W J z 1� 3 O o I u
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O� 'w °110 x 70 SE _ _ — C13 C74 C15
o
10 X 7 n irn Ct;RVt'_ +r 4
_ — — — 270.00' ` l 20, PAVEMENT 1
_c
_ _ oNE DRIVE �1 �a
0, 95.69 O
__ � /.
530.10'P Ep P ERST a6a.�s' _11 .00'
JOY FU q0%
112.00'_ J 7o f'�075-3
112.0'_ - - t
N 79 41'29" E 112.00'_ cG�•K,•nt
Utility j-`�7 cP O
1 .11
-4 1 g `O v 20 a 21
'(p l N
cn J o� o 18 0 ° A �' u
` 1� O - J rw
N O O
16 0 ° _
4 15 0 ° °
O O ; O
� 14 0 (;
14 115.37
to 111.96'
112.00'
112.00
112'00 EDITH BROWN R PMMA F
112.00' 17.86 T
12 AX LOT
1i< 7
4 MAP AP -
G 3
112.00 S 79 41'29" W 1531.09, Totol DEED BOOK 047 PAGE 206
GRAPHIC SCALE art
S L
100 0 5000 200 • F
BACK 400 h I
cl
® L
( IN FEET ) 9
1 inch = 100 fL