190 Pepperstone Dr Lot 11 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#: 5820-64-4962 0% PiPP:,rA6")
Billed To: Boan Building Subdivision Info: Pepperston Acres Lot# 11
Reference Name: Location/Address: Danner Road-27028
Proposed Facility Residence Property Size: see map
ATC Number: 4227 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 WAST O NIS ALIDPERIOD OF FIVE YEARS.
7
Environmental Health Specialist's Signa e: Date:
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
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.
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Septic System Installed By: L'J �l t z,—
Environmental Health Specialist's Signature: Date: j
DCHD 05/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street d
l
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990003768 Tax PIN/EH#: 5820-64-4962
Billed To: Boan Building Subdivision Info: Pepperston Acres Lot# 11
Reference Name: Location/Address: Danner Road-27028
Proposed Facility Residence Property Size: see map
ATC Number: 4227
**NOTE**This Improvement/Operation Permit DOES NOT authorize the construction of 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 IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type ocr #People �3 #Bedrooms 3 #Baths .2
Dishwasher: IT"'
Garbage Disposal: ET'- Washing Machine: 2'�' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial
Waste: 13Lot Size Type Water Supply 6wry Design Wastewater Flow(GPD) cc. tr
Site: New Repair❑
System Specifications: Tank Size IOCCGAL. Pump Tank GAL. Trench Width '5�if Rock Depth 12:1
2 Linear Ft.
�� Wrw� � As stated to 15Atem NCAC also
1969(5)
be used
Other.: �K accepted Systems may also be used
Required Site Modifications/Conditions:
Ell /OPERA ION PERMIT LAYOUT- APPROV D EFFLUENT FIL ER RISER(S)IF 6"BELOW
FINISHED GRADE. **** OTICE: Contact a representative of thDavie County Health epartment for final inspection of this
system between 8:30 a.m.to :30 a.m.or 1:00 p.m.to 1:30 p.m.on thf day of installation. T lephone#is(336)751-8760.****
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dUswpp&cffvsL fy hereby,Sire trnsmi to tic Aagtordad Rept+esmttthte of me Darie County HtaIW Department
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