256 Danner Road Lot 47 - z,7— o
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990003343 Tax PIN/EH#: 5820-65-3586
Billed To: Sue Earnhardt Subdivision Info: Pepperston Acres Lot#47
Reference Name: Location/Address: Danner Road-27028
Proposed Facility Residence Property Size: see map
ATC Number: 3866
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 SSmoge,TIreatment d Dis oral Systems). THIS
AUTHORIZATION FOR WASTEWATE S ION IS ALID O A PE OD OF FIVE YEARS.
Environmental Health Specialist's Signature: ate: qA111,)v -
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. 2:S-04 F.0. ZZ S1?(31< t7 4 &t11-40 ZVI#
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Septic System Installed By: �Q K eq a�
Environmental Health Specialist's Signature: Date: S�Z7'a f
DCHD 05/99(Revised)
DAME COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990003343 Tax PIN/EH#: 5820-65-3586
Billed To: Sue Earnhardt Subdivision Info: Pepperston Acres Lot#47
Reference Name: Location/Address: Danner Road-27028
Proposed Facility Residence Property Size: see map
ATC Number: 3866
**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 IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type 1 Cry #People #Bedrooms C�5 #Baths 2_
Dishwasher: S"' Garbage Disposal: ❑ Washing Machine: M 0,00, Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size'3p pts�.2 n n- �
Type Water Supply 1:�P'(iY Design Wastewater Flow(GPD) Site: New Repair❑
System Specifications: Tank Sizetpgp GAL. Pump Tank GAL. Trench Widtk it Rock Depth Linear Ft.
Other: .tel ISI�4�' 1L
Required Site Modifications/Conditions:
IMPROVE III ENT/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 8:30a. .to 9:30 a.m.or 1:00 v.m.to 1:30 n m.on the day of installation. Telephone#is(33-6)751-8760.****
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Environm�en at I Health Specialist's Signature: Date: 'Mal
DCHD 05/99(Revised)
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Aug 19 04 04:45p davie county envhealth 336 751 8786 p.2
L' uDAPPLICATION FOR SITE EVALUATION/IMPROVEMENT PERM11IT&ATC
Davie County Health Department
Envirotrmental Health Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028 J1�� O
(336)751-8760 �1
seeZHPORTANTese THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THS MUIRED ZQOA
INFORMATION IS PROVIDIM. Refer to the INFORMATION BULLETIN for instrnutions;
16
Name to be Billed pJ Co e s
.� Contj tact Parson _cS�
4Mailing Address O ��„ 5 J��ft� Nome PhonO c��f�ilStr
City/state/EIP C.Qi VA po .\ 0 ��0 4 Business Phone of O \ �e�!�f�0
7 Name on Psrsdt/ATC if ASfferent than Above
Mailing Address CAty/Stats/Z1P
,.I. Application For: ❑ Site Evaluation Improvement Permit/ATC ❑ Both
i system to service. )t HJjo//use ❑ Mobile Home 13 Business 13 Industry 13 other
/
S. Type system requested: L) C:mventional E3conventionsl modified (3 innovative
"6. If Residancet t Pe`opie a Bedrooms A _ o Bathrooms
✓VDishvasher ❑Garbage Disposal ONashing Machine ❑aasement/Plumbing ❑Basament/No Plumbing
7. If business/Industry/other. verify typo t People a Sinks
# Cosmodu t° Shovers f Urinals !Nater Coolers
IF FOODSERVICE: 0 Seater Estimated Water Usage (gallons per day)
✓ s. Typo of water supply. K County/City ❑ Well ❑ Community
9. Do you anticipate additions err expansions of the facility this system is Intended to serve?❑Yes ENO
If ycS,what type?
"*•I 0"Ti1 *0 CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. era PLA r S ITE PLAN MUST BESUBM17TED by the client with THIS APPLICATION.
—Properly Dimensions: 11 4 X oQ&U ,Y-VY I 1 q -q Xe.VRrTE DIRECTIONS(from M.,kWUte)to PROPERTY:
. Tsx Office PIN: _
—Property Address: Road Name
CltyrLip -
-76a t;
If In a Subdivision provide informrioo,as follows:
Name: t�Tr er S kolNe— I
Q 13 Section: Block: Lot: �_ Date home Corners(lagged: V o
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 falsified or changed. 1,also,understand that I am responsible jar all charges iecurred from
this application. 1,hereby.give eonsef t to the Authorized Representative of the Davie County ealth Department
to enter upon above described property located in Davie County and owned by )� . 0 e y)r i e, J�
to cond t;ll testing procedures as necessary to determine the site suitability.
,/DATE ` 'SIGNATURE
THIS AR"MAY BE USED FOR DI:AWING YOUR SITE PLAN(Include all of the following: Existing and proposed
property iinfs and dimensions,structures, setbacks, and septic locations).
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Sign given ��y Account No.
Revised DCIID(05M3 Invoice No.