159 Pepperstone Dr Lot 37 yr . 3 %... !i }. •4r.�:i qtr• Y,
1i' l Jrj.r y'y il. `i+,:"i.9 {«r..b', "i/ � ..% a = M' n.� .t y., tC{fr'.'P•:• Wei hrf 7ra,',-,.
,QUTHRIZAfI'ION NO: .� DAVIE.COLJNTY HEALTH DEPARTMENT 000
Environmental Health Section I ROPERTY INFORMATION
Permittee s P.O Box 848
Name: / ��^ .::-Mocksville,NC 27028 Subdivision Name:
Phone#'336-751-8760, r'
Directions to property: l7 O Section: Lot:
AUTHORIZATION FOR
WASTEWATER
— SYSTEM CONSTRUCTION' Tax Office PIN: 0D - -
�9
It jolt— . / Road Name: vl� Zip.D
**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.
compliance ei
with Article I 1 of G.S.Chapter 130A,Wastewater Systems,Section.] Sewage.Treatment and Disposal Systems)
P . Y ...
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS,
E RONM TA H_FALTH SPECIALIST DATE ISSUED.
57 6A.DAVIE COUNTY HEALTH DEPARTMENT /
_y I PROVEMENT AND OPERATION PERMITS PROP'ERTY INFORMATION
PermitteV *�
f ! 1
t , ..i! > Subdivision Na
Name: me:
Directions to property: h` �'T '
P Perty F •
C� Section .. Lot: .�
+ /� IMPROVEMENT _
�J '
PERMrr Ta`k Office PIN:#k�r.
Road Name. 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)
f J ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
E RONMENT H ALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE.
•..,_. - INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE _ #BEDROOMS J #BATHS O? #OCCUPANTS_ GARBAGE DISPOSAL,Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE (JITYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) / NEW SITE REPAIR SITE J,
// !� /
SYSTEM SPECIFICATIONS: TANK SIZE Dv GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH�� LINEAR FT.
OTHER - O
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT*APPROVED EFFLUENT FILTER* *RISER(S) IF 6" BELOW! FINISHED GRADE4:
_
**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 + '
(336)751-876
OPERATION PERMIT
SYSTEM INSTALLED BY: If
o
60
AUTHORIZATION NO. 14 OPERATION PERMIT B DATE: / < ��
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THATejaffM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
7
WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NOWAY BETAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96(Revised)
1
APPUCA]ION FOR SIZE EVAWATIOIII/1114PROVEMENT PERAUT 6C ATC
�► l Davie County Health Department
a [ Environmental MAJIM SeWon
P.O. Bon 848/210 Hospital Street
D Mocksville, NC 27028
Y (336)751-8760
s
qff;-*** THIS AYPLICATION CaMOT Sr PROCESSXV UNLESS ALL THE REQUIRED
Ake oft IDE�D+. Refer to the INrORMATION BULLETIN for instructions.
i. Name to be Billed � C�k&%5 )JVU LhgS contact p rsom ��322�..rC$0wS
Nailing Address 662/ 152/noes Rd- Some Phone 26 t R
city/state/zrp M n Gk5 Y- 11 E NL 9 02� Business Phone 5-23m�
2. Name on Vomit/ATC if Different than Above
Mailing Address City/state/Lip
3. Application For: U Site Evaluation iiefwrovoment permit/ATC 0 Both
4. system to servios: V House 0 Mobile Rome 0 Business 0 Industry 0 Other
S. if Residence: # people # Bedroom3 # Bathrooms
Z
V/�Dishwasher 0 Garbage Disposal WWasbinq Machine O Basement/plumbing 0 Basement/No plumbing
S. if Business/Industry/Other: specify type # People # sinks
# Commodes # Showers # urinals # hater Coolers
IF FOODSERVICE: # Seats Estimated Mater Usage (gallons per day)
7. Tppe of water supply: U County/City O Well a Community
s. Do you anticipate additions or expansions of the facility this system Is intended to serve? 0 Yes VINO
if yes,what type.
***IMPVRTANT'**CLIENTS AlUSTCVAlPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Etcher a PLAT or SITE PLAN AtUST BRSUBMITIED by the cleat with THIS APPLICATION.
Property Dimensions: _]l.Tx 2UP 4 A57,K 27.3 - WRITE DIRECTIONS(from Moctuvllle)to PROPERTY:
Tax Office PIN: # �5$Za G,:�' 0314-:9- .004�l y p D it 0A i}, 12 115 'O 0 1)nyr it"'!'Z
Property Address: Road Name P-='PR_1Rsibrta $Zig.,. b ` i5 k,,r Orf i`�eppe s ty�-►� D 1Z
Citymp_ MOC.KS✓-.7/E ,.tic- k0 1 37 yNIf in a Subdivision provide information,as follows:
Name: pz�Fp?ep'5-re1'i c
Section: Block: Lot: Date Property Flagged: 5— 13
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 1,also,andaxta nd that t am nVonstblr for all charga incurred f vw
AAs appllra don. 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 procedures as necessary to determine the site sul
DATE. .S'��_j�` SIGNATURE '
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN( dude all of the following: Existing and proposed
property Hues and dimensions, structures, setbacks, and septic locations).
( Account NO. °�0
Revised DCHD(07/98) �'( Invoice Na
�i,