214 Danner Road Lot 43 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 989900204 Tax PIN/EH#: 5820-55-8694
Billed To: J. D. Crews Homebuilder Subdivision Info: Pepperstone Acres Lot#43
Reference Name: Location/Address: Danner Road-27028
Proposed Facility: house Property Size:
** *Vffb7r. 2476
N is mprovement/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 IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type #People #Bedrooms #Baths .S
Dishwasher: ®Garbage Disposal:❑ Washing Machine: B-�Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift �i#S,c�ats Industrial Waste: ❑
Lot Size,= q1I) Type Water Supply Design Wastewater Flow(GPD);�(�U l Site: New B Repair❑
System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width, Rock Depth Linear Ft /
Other:
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Required Site Modifications/Conditions:
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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Environmental Health Specialist's Signature: Date: '7—[o
DCHD 05/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 989900204 Tax PIN/EH#: 5820-55-8694
Billed To: J. D. Crews Homebuilder Subdivision Info: Pepperstone Acres Lot#43
Reference Name: Location/Address: Danner Road-27028
Proposed Facility: house Property Size:
ATC Number. 2476
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 WASTEWATER C TRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: 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 I I 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
iven period of tim .
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Septic System Installed By: / i�nM
Environmental Health Specialist's Signature: Date: 7 G,n e
DCHD 05/99(Revised)
APPUCAMON FOR SITE IMMllAMWIMPROVEMERT PERMIT d AT
Davie County Health Deparbnent
Envitvnrnenta/KwNb.i ewon JUL 5 2000
P.O. Box 848/210 Hospital Street
Moaksville, LIC 27028
(336)751-8760 ENVIRONMENTAL HLTH
I
***ZWOIt"IXr*** THIS APPLICATICU tiU=r IM PMMSSW UNLESS ALL THE REQ1IR11D
INFORMATION ZS PROVIDED. Refer to the INIiOR491TMON BUWZTIN for instructions.
1�1
i. lease to be Billed u_ D C�-w SAE U'�,t,D�c-RS c:ontaat Person 1 LKG�S
Hailing Address �D jL_mORC Hees Phone 3310 •-4�(L- ?�ol�}'
City/state/HIP m oc*ks-y i 11` )JG a20?;? Business Phone smn._
2. Wan on Peralt/ATC if Different than Above
Nailing Address City/state/Zip
3. Application For: U Site ftaluation l/Improvaiwnt Permit/ATC 0 Both
4. systen to service: W house 0 Mobile Home 0 Business 0 Industry 0 Other
s. if E=v idence: f People 3 4 Bedrooms 3 I Bathrooms Aa
ly Dishwasher 0 Oarhage Disposal K Nasunq machine 0 Basement/Plumbing 0 Bast/No Plumbing
6. If Business/Industry/Other: specify type / People • Sinks
/ Commodes # showers t# Urinals # (eater Coolers
IF FOODSBBPICE: # Seats 8stimated (later Usage (gallons per day)
7. Tpp• of water supply: t/County/City 0 Well 0 Comity
e. Do you anticipate additions or expotsions of the facility this system is intended to serve! 0 Yes "/0
If yes,what type.
***IMPIDRrANP**CLIENTS AtUST C7OAtPLETETHE REpUIRED PROPERTY INFORMATION REQUESTED
BELOW. -Either a PLAT or SITE PLAN MUST BESUBMITTED Oy the ciknt with THIS APPLICATION.
Property Dimensions: ,AJ2'X 99d')(.-5S'X 24g WRITE DIRECI70NS(from MocksWik)to PROPERTY:
Tax OtncePIN: d SSZo— � 86rt� Nw� 601 1V0•eU--M9iJ R)qi-r Uhl bnw6j rt A�-
Property Address: Road Name D.4A/A/t'P- P-J- J-uSi P AgAegswe oN ei5 kT
City/Zip- fi 0C'k6VJ I l e,,,tJ L2zP�8
If in a Subdivision provide information,as follows:
Name: P4DPPS i1)Nc /}cP&-S
Section: Block: Lot: Date Property)Flagged: 74- 00
This is to certify that the information provided Is correct to the best of my knowledge. I understand that any permit(s)
issued bereafter are subject to erspensW or revocation,if the site pians or Intended use change,or If the information
submitted in ibis applicatlos is falsitkd or changed. 1,alto,andeestand that I ace reVon"ejor all charges lncxrered from
rhls
_- ..,°PPa. r.a n. I., y
,oa io» eet!e!fie-Aa#.b3riz*tReprowtative of:5c DtIc Coo atg flealth_LepsTtcDt---
to enter"poi above described property located In Davie-County and owned by
to conduct all testing procedures as necessary to determine the site saltability.
DATE z yD SIGNATURE LIAd=1 41v_x_�
THIS AttF.A MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
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Account Na
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Revised DCHD(07198) to Invoice No. 1 0
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