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125 Pepperstone Dr Lot 40 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 989900204 Tax PIN/EH#: 5820-55-7437.40 Billed To: J. D. Crews Homebuilder Subdivision Info: Pepperston Acres Lot#40 Reference Name: Jerry Crews Location/Address: Pepperstone Drive-27028 Proposed Facility: Residence Property Size: 3/4 Acre ATC Number. 2196 **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 AQO"-'c #People #Bedrooms -7�> #Baths .Z Dishwasher: O'�- Garbage Disposal: ❑ Washing Machine: 19"' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 314J Acs Type Water Supply eint-JDesign Wastewater Flow(GPD) C o Site: New®--`iepair❑ System Specifications: Tank Size ICCOGAL. Pump Tank GAL. Trench Width- � Rock Depth J Z'� Linear Ft� Other: Z 'Dt9Tatsu- no.J ?ovx--S I,-Is ku- 1 i----S 9'©.c• Required Site Modifications/Conditions: 1-%e ' LL 0-5 C---ho-j2, aa' 1-IoJS�. IC p �O`oFF &P. U As IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6 L°BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this tem between 8:3 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.**** Id „ rA TZ' �`ti V S 'Do +' 0 1 \ X00 Environmental Health Specialist's Signature Date: /O 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#: 5820-55-7437.40 Billed To: J. D. Crews Homebuilder Subdivision Info: Pepperston Acres Lot#40 Reference Name: Jerry Crews Location/Address: Pepperstone Drive-27028 Proposed Facility: Residence Property Size: 3/4 Acre ATC Number: 2196 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 reatment and Disposal Systems). THIS AUTHORIZATION FOR WASTE WA C TION S VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signatu 7) Date:- &>/�/w 4) C11 165;;1 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. d� .>1 a° � s< Septic System Installed By: Z Environmental Health Specialist's Signature(�� Date: 2 2� DCHD 05/99(Revised) APPUCATION FOR SITE EVAUMION/1101PROVEMENf PERM b ATC M Davie County Health Department L5 f5 U Env1tVnntenfa/HMO SeWon OCTP.O. Box 648/210 Hospital Street OC — 7 1999 Moakaville, HC 27028 (336)751-8760 ENVIRONMENTAL HEALTH ***Z pOHTAN"** THIS APPLICATION CSPOr BS BROCESSLD UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Reefer to the InvRMATION SUMIATIN for instructions. 1. Mame to be Billed c (Z 7, I�O ur►�'Qil tf��lc s Contact Person cggi`�pZ g cp'0:22 Mailing Address 'JO E/ /1't oRE aq p,0 scow Phone City/state/ZIP M 0cgs I I�,r IvG dt70�2E Business Phone Z. Name on Permit/ATC if Different that Above Nailing Address City/state/Zip 3. Application For: U Site Evaluation 04mprovemesnt Permit/ATC 0 Both 4. System to service: t/House 0 Mobile Home 0 Business 0 Industry 0 Other s. If Residence: i People spau's". i Bedrooms 3 i Bathrooms V/Dishvasher 0 Garbage Disposal 4/washing Machine 0 Basement/Plumbing 0 Basement/No Plumbing 6. 2f Business/Zndustry/other: Specify type # People # sinks i Caw•oodes Shovers # Urinals # Nater Coolers IF FOODSERVICE: d Seats Estimated stater Osage (gallons per day) 7.- Type of water supply: R/County/City ❑ well ❑ Como unity e. Do you anticipate additions or eipaasions of the facility this system is intended to serve! 0 Yes BINo If yes,what type. "'IMPORTANT "CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED ky the client with THIS APPLICATION. Property Dimensions: 10/3Z X. ,VOX L1%6JK`X?RA,6o WRITE DIRECTIONS(from Mocipville)to PROPERTY: Tax Office PIN: t!_ SS a0 -S.T- *7 gaz 14W I toA 1 Nve'I-A 'j q eq Property Address: Road Name RoRgeswaa D+2. ANNeP, RA. 119z1f.1 R-ici kT- otJ City/Zip z 7or'r P$ i�PER,S?i Oe a R, /—Or 40 04/ If in a Subdivision provide Information,as follows: l-E - S;d r•/ onl G.OT Name: �t �R.StOhtr Section: Block: Lot: Date Property Flagged: 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 pians or Intended use change,or If the Information submitted in this application Is falsified or changed. I,also,understand that I ani responsible for all charges Incurred froom this applkaadon. I,hereby,give consent to the Auti oriwA Representative of the Davie County Health Department to enter upon above described property located In Davie County and owned by to conduct all testing procedures as necessary to determine the site adtabi ' DATE I 1'7 I el el SIGNATURE THIS AREA MAYBE USED FOR DRAWING YOUR SITZ PLAN(Include ail of the following: Esiating and proposed property lines and dimensions, structures, setbacks, and septic locations). o Account No. Revise DCHD(0IR So Invoice No. �a��Y