172 Pepperstone Dr Lot 9 cYs•...r;-,•coa
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a ,T ItiZATION NO: DAVIE CLUNTY HEALTH DEPARTMENT
+� knAronmental Health Section PROPERTY INFORMATION
Permittee's P P.O. Box 848
Name: �/� �� s � �� Mocksville,NC 27028, Subdivision Name:
Phone# 336-751-8760
Directions to property: 41 r'iS !ivE 'L'� Section: Lot:'
AUTHORIZATION FOR (/•.ryry
WASTEWATER Tax Office PIN:# aoSQ_
SYSTEM CONSTRUCTION .
Road Name:.-Zip:
**NOTE**"This Authorisation 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
!� ?(r �j� IS VALID FOR PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPE IALIST DATE ISSUED
477! .wy ,�+•pGr..4.ik�yr.n.� '+"^ u.:trb iyi .'ri. ''.--..n`.+. s ..c.�,,,,..-.y..+. u..... .-;�,.J. _ r ,.Y. ;', .1,.c-: ,:' :,..� ,, ty.w.,..:.- ..Yl..rn w•.n
1,7 3 8 -DAVIE C UNTY HEALTH DEPARTMENT 4
- IMPRO ,EMENT AND OPERATION PERMITS PROPERTY.INFORMATION
-
,�► + � Subdivision Name: "'�L� lei
YName fC' Di `
DiFections to property`. Section: / Lot:'
71- DAPROVEMENT f
PERMIT. Tax Office PIN:# &O 40
Road Name: ! Zip: / y
i **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)
/• r ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
[.` s✓� 3. /r�' ./f PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
-,EN VIRONMENTAL HEALTH SP IALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM. 0,4•
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS, „�#BATHS�#OCCUPANTS -S' GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE/1 #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY C DESIGN WASTEWATER FLOW(GPD)2 NEW SITE +�' REPAIR SITE
��. iy
SYSTEM SPECIFICATIONS: TANK SIZ��/� GAL. PUMP TANK GAL. TRENCH WIDTH� ROCK DEPTH L LINEAR FT. eC
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
E
NTACT 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)751-8760.
OPERATION PERMIT �� �hn i e_ La Gtr
SYSTE STALLED Y:
10V em-4
AUTHORIZATION NO. I OPERATION PERMIT BY: DATE:
"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 A
------------
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96(Revised)
i .
APPUCAHON FOR SITE EVAWATION/IMPROVEMENT PERMIT do
Davie County Health Department 3V
En Wtvnmenfal Healfh SmWon
P.O. Box 848/210 Hospital street WV -3
Mockaville, NC 27028 flu`
(336)751-8760
Q•Mitor.n UAt tEALTH
***Il�ORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. dame to be Billed 1'ra n�4 Con Go, Contact'Person /'/,' e
Mailing Address Sax 1-23 game Phone A 1-2- L/5 z•- y 2 2 �
City/state/SIP _ C/t c�C✓Son ) N, C— 2-7 r � Business Phone 2 S'2 4`/2 f 6-7 5
Z. flame an Pewit/ATC if Different than Above See•Y►e a,5 q�bDy(:
Mailing Address City/ tate/Zip
3. Application For: IJ Site Evaluation IZVrovement Permit/ATC 0 Both
4. system to service: H House 0 Mobile Home 9 Bumir+a- U`.7nfustr- '0 Other
a. If Residence: # People _ # Bedroom � # Bathrooms 2-
V/Dishwasher
e Dishwasher 11 oasbage Disposal U Mashing Machine O Basement/Plumbing D Basement/No Pluabing
6. If Business/Industry/other: specify type # People sinks
# Coomodes # showers # Urinals # )later Coolers
IF FOODSERVICE: # Seats Estimated slater Osage tgailons per day)
7. Type of water supply: N County/City 0 Well 0 Community
8. Do you anticipate additions or expansions of the facility this system is Intended to serve? 0 Yes IYIVo
U yes,what type'
*"IMPORTANT'CLIENTS 11IUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST RESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: / X 2 9 5-1162 ?Qq5 WRITE D=CTIONS(from Mockrvtlle)to PROPERTY:
Tax Office PIN: #�D o2���PN9 o0o �
Property Address: Road Name /fie P8,Pj r--*) no Dei_✓e
CityrLIp/ll�f I4 k 2/0i23 LUl 0 6A .A
If in a Subdivision provide Information,as follows:
Name: Pe-PR Peen.
Section: _�_ Block: A Lot: �_ Date Property Flagged: 3 g
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 falsiQed or changed I,also,understand that l am responsible for all charges incuffedfrom
this application. I,hereby,give consent to the Authorized Representative of the Davi County Health Department
to enter upon above described property located in Davie County and owned by c ✓e
to conduct all testing procedures as necessary to determine the site suitability.
DATE 0 3 d SIGNATURE '4j
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(InLe all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Account No.
Revised DCHD(07198) Invoice No. Sod
166.18'
83.171
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)T * 73 MAP G-3 d ! �__,,, `9 79 TAX LOT • 74 MAP G-3
500K 36 PAGE 99 — ' �g Y" DeeD BOOK 47 PAGC 206
or A FD AT ALL LOT CORNERS UNLESS OTHI=RWISI` ED.NOT
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