The URL can be used to link to this page

117 Pepperstone Dr Lot 41 DAVIE COUNTY HEALTH DEPARTMENT ` Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 989900204 Tax PIN/EH#: 5820-55-6564.41JDC Billed To: J. D. Crews Homebuilder Subdivision Info: Pepperston Acres Lot#41 Reference Name: Location/Address: Pepperstone Drive-27028 Proposed Facility Residence Property Size: 3/4 acre ATC Number: 3975 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewa reatment and Disposal Systems). THIS AUTHORIZATION FOR WASTE SU O IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's SignaC Date: los– CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S.Chapt 30A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY be taken as a gu t t e system will function satisfactorily for any given period of time. w O ,q O Sg f � Septic System Installed By: �^ 3" C�$D1 &`f F34CV–L D-� Environmental Health Specialist's Signature: Date: c— DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT ,' Account #: 989900204 Tax PIN/EH#: 5820-55-6564.41JDC Billed To: J. D. Crews Homebuilder Subdivision Info: Pepperston Acres Lot#41 Reference Name: Location/Address: Pepperstone Drive-27028 Proposed Facility Residence Property Size: 3/4 acre ATC Number: 3975 **NOTE**This Improvement/Operation Permit DOES NOT authorize the construction 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). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type_ . #People #Bedrooms #Baths Dishwasher: Garbage Disposal: O Washing Machine: El'-- Basement w/Plumbing: 13 Basement/No Plumbing: Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: Lot Size :51q Type Water Supply CAW Design Wastewater Flow(GPD) --'kV0 Site: New Er Repair 1 c System Specifications: Tank Size 181; GAL. Pump Tank GAL. Trench Width�f Rock Depth ZI Linear Ft.? Other: Required Site Modifications/Conditions: )hZ61AU- C fi61�Q. t0 klr,40-�y,J 0 IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISERS)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of inqallat%on. Telephone#is(336)751-8760.**** P foo' Environmental Health Specialist's Signature: Date: r— DCHD 05/99(Revised) • DAVIE COUNTY HEALTH DEPARTMENT leod /e, Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900204 Tax PIN/EH#: 5820-55-6564.41 Billed To: J. D. Crews Homebuilder Subdivision Info: Pepperston Acres Lot#41 -Reference Name: Jerry Crews Location/Address: Pepperstone Drive-27028 Proposed Facility: Residence Property Size: 3/4 Acre ATC Number: 2195 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction 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). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type 00aS6 #People #Bedrooms #Baths 7— Dishwasher: Dishwasher: IT"' Garbage Disposal: ❑ Washing Machine: 0"' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size !VL4 ACQx Type Water Supply(2-00^4W Design Wastewater Flow(GPD) 3(,g0 Site: New 2-**�Repair❑ System Specifications: Tank Sizel 00CiAL. Pump Tank GAL. Trench Width�Q Rock Depth IZrr Linear Ft.�r Other: ( jiSTP�t P�Tto--� �tj�Ci, �►,1STe.l1_- 1,�.��S 91 tb •C.. Required Site Modifications/Conditions: "'y'- LL O'� LUr�1'rIIc�� S"Cxr- )ot Pmt". LtA IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6-BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this s tem between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** q2" l O r w�r J. P��, la 41� r d CI Environmental Health Specialist's Signature: Date:, /Q// 9 DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account M 989900204 Tax PIN/EH#: 5820-55-6564.41 Billed To: J. D. Crews Homebuilder Subdivision Info: Pepperston Acres Lot#41 Reference Name: Jerry Crews Location/Address: Pepperstone Drive-27028 Proposed Facility: Residence Property Size: 3/4 Acre ATC Number. 2195 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTE ueTIPN IS ALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signa Date: /D CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit 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. Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) APPLICATION FOR SITE EVALUATION/iMPROVEMEM PERMIT A ATC Davie County Health Department 4 Environmental ffiWO SOW= P.O. Box 868/210 Hospital Street _ 7 I Mockaville, INC 27028 (336)751-8760 UNIRONM ***XWORTANT*** THIS APPLICATION CANNOT BE PROMSM UNLESS ALL IN PAMTION IS PR-OOMED. Refer to the INSOAM UCH BULLETIN for instructions. 1. Naim to be Billed J //D Ckmas n1EnahL = Contact Person .��Y �G-W S '' Mailing Address 'TO/ jEL M 12Rt5 -ROArl Some phone 9.Z- 7(0/ City/State/8Ip M OCKS V i LC'E10 Ale- 2702-8 Business phone s 14�vu� 2. Name on Pe=lt/ATC if Different than Above Mailing A4dxess city/State/Zip 3. Application For: U Site Evaluation &O' Vrovement Permit/ATC 0 Both 4. system to service: wSouse 0 Mobile Home 0 Business 0 Industry 0 Other Spm' s. If Rasidence: # People Nausi # Bedrooms .3 # Bathrooms .71V/oishwasher U Garbage Disposal I,Washing Maclaine O Basement/plumbing O Basement/No plumbing 6. If Business/Industry/other: Specify type - # People # Sinks # Commodes # Showers y # urinals O # Nater Coolers 0 IF FOODSERVICE: Seats Estimated Water Osage (gallons per day) 7. Type of water supply: fY County/City 0 Well 0 Conn unity a. Do you anticipate additions or expansions of the facility this system is intended to serve! 0 Yes I N0 U yes,What type' ***1JifP0RTANT***CLIENTS AIUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUSTBESUBM117EN1 the client with THIS APPLICATION. Property Dimensions: 1835 -J0 Waco,IQg,3i"�X ,Oo' WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tai Office PIN: # :58.7,0..SS -X56 r � I�IJO 11/DRTFf� -- 7ZCP.n1 (�iE l Dnf Property Address: Road Name_ PlaFe-smac tom. DAW Iia E�J - IUZi gof R ic�A,-r' od City/Zip MOGk5✓,IIC 1�C Z'jo PePPEkB?t�N� DTZ. I-V OIC if in a Subdivision provide Information,as follows: j-b Si`4 tJ Name: 4)rap ipags-mnlc Section: Block: Lot: l _ Date Property Flagged: ZO - Ibis 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,xnAnWand that I ant responsible for all charge(incurred frons this_appllcadon. 1,hereby,give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procures as necessary to determine the site suitability. DATE x_'19 9 SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). o . � o O Account No. Revised D(07/98) ( Invoice No. w 5y. f4