177 Pepperstone Dr Lot 35 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990003768 Tax PIN/EH#: 5820-65-2370
Billed To: Boan Building Subdivision Info: Pepperston Acres Lot#35
Reference Name: Location/Address: Danner Road-27028
Proposed Facility Residence Property Size: see map
ATC Number: 4228 As stated In 15A NCAC 18A.1969(5)
accepted Systems may also be used
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 WASTEW N V OR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date: b OS
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
1,p 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 th the system will function satisfactorily for any
given period of time.
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Septic System Instal ed By:
Environmental Health Specialist's Signature: Date: —l
6.0
DCHD 05/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT /o
' Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990003768 Tax PIN/EH#: 5820-65-2370
Billed To: Boan Building Subdivision Info: Pepperston Acres Lot#35
Reference Name: Location/Address: Danner Road-27028
Proposed Facility Residence Property Size: see map
ATC Number: 4228
**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 EF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS/'PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type fie- #People '"f #Bedrooms' #Baths 2-
Dishwasher:
Dishwasher: 13"' Garbage Disposal: 2"'- Washing Machine: 13"'- Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste:
Lot Size 3D1=42 Type Water Supply rrrY Design Wastewater Flow(GPD)-3W Site: New 0""Repair❑
System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width,?v' Rock Depth 17— Linear Ft.
As stated in 15A NCAC 18A.1969(5)
Other.: q /q��� accepted Systems may also be usecdl
Required Site Modifications/Conditions: kna- @ejr-4 �
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
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 installation. Telephone#is(336)751-8760.****
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Enyironm ea th Specialist's Signature: Date: b
DCHD 05/99(Revised)
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This u to aufity that the tamrnmtlon protidat h:correct ti the bat ofroy katn►iedge I Dadstsraiul that any pernsit(t)
issued hereafter aresabled to suspension arrevontion,If the siteptans or iaieaded use ehomM or tf the taforvandon
snbnittal in this apptieatian D tatsiBed or ehaaged.!,dfay.uatdmLrsd ttidluar raparisr�ttjare/l dmrY,asfmArradlrom
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to atter upon above described property locale!in Davie Cimtty amr onutdlrs
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