130 Pepperstone Dr Lot 4 v
DAVIE COUNTY HEALTH DEPARTMENT ,
C__-- IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PERMIT
##NOTE*f This improvement permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater
system. - '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 .19M Sewage Treatment and Disposal Systems)
NAME- 11'1?1111 I-A4ylr PROPERTY ADDRESS __ 'Y)�t e v' aL. _ DATE
LOCATION l
SUBDIVISION NAME p z he- //C LOT NUMBER 14 SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE Alvan e # BEDROOMS ,.? # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes
COMMERCIAL'VECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE TYPE WATER SUPPLY 9_ DESIGN WASTEWATER FLOW (GPD) .-FO'd FEW SITE L-'REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE/O�� GAL. PUMP TANK GAL. TRENCH WIDTH 3�„ ROCK DEPTH / �• LINEAR FT. ,?ed
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
*e}THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
IMPROVEMENT PERMIT BY ��f�
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPAR F FINAL INSPECTION OF THIS SYSTEM BETWEEN
8:30-9:30 A.M. OR 1:00-1:30 P.M. ON THE DAY OF INSTALLATI EPHONE # IS 1:136 3 �- 498.
1�
3L-7S/-dr7
OPERATION PERMIT SYSTEM I T D BY
l�
AUTHORIZATION NO. OPERATION PERMIT BY DATE
T
*+THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT 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 AI
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 10/95
. , FE .
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER
Davie County Health Department
Environmental Health Section W
P. 0. Box 665
Mocksville, NC 27028 NEALTH
/�/�ZG� NTY
1. Application/Permit Requested By CW G
Mailing Address ! Home Phone
Business Phone
2. Name on Permit if Different than Above
3.Application for: ❑General Evaluation eptic Tank Installation Permit
4. System to Serve: ClIKOuse ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ ther ❑ Unknown I
5. If house, mobile home: Subdivision W Section Lot # c
❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms ❑ Washing Machine
No. of Bathrooms -1 Dishwasher
Dwelling Dimensions 2 1� �— ❑ Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
No..of Commodes No. of Urinals kk:
No. of Lavatories No. of Water Coolers t
No. of Showers Water Usage Figures
7. Type of water supply: ublic ❑ Private ❑ Community '
8: Property Dimensions Sewage Disposal Contractor
9.'Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No
If yes, what type? 4
t I
'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvementst Permits are subject to I
revocation, if site plans or the intended use change. Effective October 1, 1989. ;
PROPERTY INFORMATION REQUIRED:
t>
Directions to Property: Tax Office PIN
Road Name — L
L
Box # (if available)
City k
1
4
i
F:
F
,
This is to certify that the information provided is correct to the best of my knowledge, and I understand am resp sible for all charges
incurred from this application. ' f
7 's
DATE SIG RE
,
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: E31. 1 OWN the property. CI 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I 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 procedures as necessary to determine said site's suitability for a r and a rption sewage treatment
and disposal system.
DATE SIGNATURE
F
DCHD(1193)
Davie County Health Department �+
ENVIRONMENTAL HEALTH SECTION »�
P.O. Box*15-2144'
Mocksville, N.C. 27028 -
AUTHORIZATION FOR WASTEWATER SYSTEM DXTRUCTION
(Issued in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems)
***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.*** ui/�e/�s '/7/9
-- /�'��SAUTHORIZATION NUMBER
NAGE /_Yl�/i"4),l DATE 5�� SJ
2
MITE ON IlPROVQENT PERMIT (If different than above)
SITE LOMATID)i 1pe4 Y
COM WS/CONDITIONS ON AUTHORIZATIO .TO CONSTRUCT WASTEWATER SYSTEM
#*00TICE*ff THIS AUTHORIZATION FOR WA TER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
ENVIRONWAI OLTH SPECIALIST. DATE
DCIM 10/95