180 Pepperstone Dr Lot 10 t"+('< __ e;i ll.+fft.i�"t'.' , - ��,42s :,x Y:^-'��.. 't.'i-= - `��-'+s-•5.�""' "�..,,�.... 'i Ft mak'�.'��`� '�.�'�-'�'E'" E'iL'•i n7 r.� til i`:3j ",y-.,: '" •.,• i�>
�:. DA X0
AU-T IOR12ATION NO: 16 6 0 . DAVIE CJJUNTY'HEALTH DEPARTMENT
environmental Health Section PROPERTY INFORMATION
Permittee's- t� 1+ � P.O.Box 848
Name: '+��`'4 4 Mocksville,NC 27028 Subdivision Name: J�
,f1�n��„� Phone# 336-751-8760 ` 10
'.Directions to property: u�J �•'�� Section: / ,Lot:
AUTHORIZATION FOR
WASTEWATER Tax ffice PIN:#5�V
SYSTEM CONSTRUCTION elltalooe
ty
Road Ndme: im 4Q
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building-Pemnits.This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Pen-nits.
(In compliance with Article I l of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
r� . ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION G
�� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
t. `" r1660
;R, DAVIE OUNTY.HEALTH DEPARTMENT
t �'-
IMPROVEMENT ANOPERATION PERMITS PROPERTY INFORMA
D A
TION
Subdivision Name: +V�
�T
Directions to pr erty: v ^%%ii7 ' Section: Lot:' ,
IMPROVEMENT
s PERMIT Tax Office PIN•#
Road Nme. Zip:r.
**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
constructionlmstallation of a system or the issuance of a building permit.,
M compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THUS PERMIT IS SUBJECT TO REVOCATION IF SITE
" ! PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER '
t• SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDINGTYPE_ #BEDROOMS #BATHS _#OCCUPANTS .3 GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLF/SHIFT #SEATS INDUSTRIAL WASTE_:Yes or No
LOT SIZE�� %/�� TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANKS —&11-6—GAL. PUMP TANK' GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. 70d
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT.
"CONTACT A REPRESENTATIVE OF THE DAVIE COUN EALT DEPAR ENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON DAY INSTA ATION.TELEPHONE#IS (336)751-8760.
OPERATION PERMIT
SYSTE INST LLED Y:
AUTHORIZATION NO. OPERATION PERMIT BY:
"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)
' APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Q 71MM,Davie County Health DepartmentEnvironmental Health Se�cf3on
P.O. Box 848/210 Hospital Street SEP
Mocksville, NC 27028
(336)751-8760
ENVIRO SME O H UH
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE QUIRED
INFORMATION IS PROVIDED.
+ )Refer to the INFORMATION BULLETIN for
!jinstructions.
1. Name to be Billed J(�! -r- /W�I ISO n Contact Person e�l� W i I s 0 I
Mailing Address oa /S /"►-�N,[ /D tt Q;h same Phone I O ZLj 5
City/State/ZIP M 6CIS V I I k A r - Business Phone
2. Name on Permit/ATC If Different than Above
Mailing Address City/state/Zip
3. Application For: IJ Site Evaluation yImprovement Permit/ATC ❑ Both
4. system to service: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
a. If Residence: # People ' _ # Bedrooms J # Bathrooms
XD 1shwasher XGarbage Disposal XWashing Machine 0 Basement/Plumbing 0 Basement/No Plumbing
6. if Business/industry/Other: specify type # People # sinks
# Commodea # showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (galions per day)
7. Type of water supply: County/City ❑ Well ❑ community
e. Do you anticipate additions or expansions of the facility this system Is intended to serve? ❑Yes �No
If yes,what type?
***IMPORTANT"**CLIENTS AIUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Eitber a PLAT or SITE PLAN MUST BESUflMITTED by the client with THIS APPLICATION.
Property Dimensions: — r `7 j� VIRI'I�DIRECTIONS(from Mocknille)to PROPERTY:
N��"V" �' -3
Tax Office PIN: # /off In AJ a
Property Address: Road Name 2cpPtr S`bnc- 12r^• a n:e Y- R d – R
city/zip til.o as i/; I(e- b i-� p-p a✓1-P rS-hi,ne-
If in a Subdivision provide information,as follows: + I1
Name: 2DD�GrE' OY)�
P
Section: Block: Lot: Date Property Flagged: li_ d 99
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 apolication is falsified or changed. I,also,understand that I am responsible for all charges incurred from
this application. 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 r11 testing procedures as necessary to determine the site suitability. /
DATE i _nt �� SIGNATUREJL
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(include all of the following: Existing and proposed
p-aperty lines and dimensions, structures, setbacks, and septic locations).
Account No. d
Revised DCHD(07/98) Invoice No. o a�
1060
_ fu100.00' SHEET 1 OF 2
to
O toc
I" ou
3$ 3 m
Z,^ � m Z
PEPPERSTONE ACRES
n �� n v
2 ,h ;3s h =
< r I�I m 35O J SUB—DIVISION
- n N34 �' *I � Ct
1p 07' ri1 �� a a J t° `' OWNER—DEVELOPER
1js ops _ z CLAUDE R. HORN, JR.
5.66-
_ ` um�i 190 NORTH MAIN STREET
p0' Y eo,�rnont MOCKSVILLE, N. C. 27028
a pEpP4! S�' .c0, _ TELEPHONE: 704/634-2181
_ ON s _
115_p°, S 7g�°3'04„ ORI V 8.a1, C3— - _ _ _ — — �47.5a o
e C4 C5 �° BEING TAX LOT 99 / TAX MAP F-3
11$'°O� 421 g8� r PUBLIC � 0o9�e�ry f RECORDED IN DEED BOOK 142 FACE 636
_ X15.00' CURVE * 2
N i9e 41'29�� CLARKSVILLE TOWNSHIP
— ce _C6 no o DAVIE COUNTY, N.C.
11 m
,c
3
"a
w
n O N 3 1�2 �a
r n g h ° - ,• SURVEYED NOVEMBER 2,1994
o O ^ 0 3 s 86.54'4x" w -'' �* 19.57' BY KENNETH L. FOSTER
O o 3 �ss.7s/ to 12 R.L.S. 2552
i I� C., O t0 rA O N f / / �/ O►1 O
v- o N 1 Zr) o c�xR+:ra 3 TOTAL AREA = 45.011 ACRES ( DMD )
Q N O 0
1. ' 88.84
13d.1�' _J1100 69.20' p6.Vi6il C
118.22 0/1 N ► S 86.1+'57 � s 58.05' GU PTON—FOSTER ASSOCIATES, P.A.
N 83.54'p n 1p9.89' — —
° w — R SURVEYORS
1
ENGINEERS—PLANNERS 9.98,
256.37 N � � � ,
7812,p44 w 19 , 1e5.z+ 2200 SILAS CREEK PKWY.
a7' N e SUITE 28
633 , 3> 150.00' �15.24�
4
13 3 „ .,s, „ W WINSTON—SALEM, N.C. 27103
aoo
CATHERINE
} BAKER3 MAP G-3 6?s'8 w 5 79 41'29 EDITH DROWN RUMMAGE )AM,
DASD ROOK 38 PAGE 99 _ �I$�' TAX LOT + 74 MAP G-5 TELEPHONE: 910-723-2459
— � DEED ROOK 47 PAGE 206
VOTE. IRON PINS PLACED AT ALL LOT CORNERS UNLESS OTHERWISE NOTED. JOB NQS 93G.",
NOTE: NO GEODETIC CONTROL MONUMENTS POUND WITHIN 2600 FEET. GADO " JP*
�r cmwx a m
t
----°—