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264 Danner Road Lot 48 DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 989900216 Tax PIN/EH#: 5820-654594.48 Billed To: Paul Willard Subdivision Info: Pepperstone Lot#48 Reference Name: Location/Address: Danner Road-27028 ATC Number: 4291 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 CO STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: v CERTIFICATE OF COMPLETION coo Z,'t%e **NOTE** The issuance o his Certificate of Completion shall indicate the system n Improvement/Operation Permit has been installin compliance with Article 11 of G.S.Chapter 130A, 6Won.1 00"Sewage Treatment and Disposal System ,"but shall in NO WAY be taken as a guarantee that t system 'll function satisfactorily for any given period of t e. 10 t,-A, iler's Q � Li Septic System Installed By: 1 -11,4 / ,4 r Environmental Health Specialist's Signature: Date: 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 #: 989900216 Tax PIN/EH#: 5820-65-4594 Billed To: Paul Willard Subdivision Info: Pepperstone Lot#48 Reference Name: Glenda Willard Location/Address: Danner Road-27028 Proposed Facility: Residence Property Size: 1 Acer **NOT *ThIslmprovement/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 #Bedroomsy #Baths_ Dishwasher: Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste:❑ Lot Size Type Water Supply_ Design Wastewater Flow(GPD) - Site: New JQ Repair❑ System Specifications: Tank SizevGAL. Pump Tank GAL. Trench Widt � Rock Depth/ rLinear F� Other: As stated in 1-9A NCAC 18A.1969(5) ': accepted Systems may also be use 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.**** Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) .y -i 4a a T� APPLICATION FOR SITE EVALUA710N/IAIPROVEMEN71'ERM1Rn I Davie County Health Department • - _ Environments/Health Section � D F+., � 4 2005 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 EMIIRONMEMALHEALTH DAVIE COWJ,Y ***II'IPORTANT*** TIiIS' APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORI-MTION IS PROVIDED. Refer to the INFOMIATION BULLETIN for instructions. 1. Name Lo be Billed (�� )�Qed/)jf, Contact Person ),M Nailing Address �� '1?/(r�� Home Phone � �r'01:5 / City/State/ZIP DG S v f II �C s2�D Business Phone .Scam P 2. Name on Permit/ATC if Different than Above Nailing Address City/State/Zip J. Application For: ��Ek'.161te Evaluation ❑ Improvement Permit/ATC ❑ Doth 4. Sys Lem to Service: IIounse ❑ Mobile Homes ❑ Business ❑ Industry ❑ Other S. Typo syntem requested: ❑ Conventional ❑ conventional modified ❑ innovative r3aCCepted 6. If Zesidence: # People � # Bedrooms -13 � � it Bathrooms — <1J�Dishwasher []Garbage Disposal 01ashing Machine ❑Basement/Plumbing ❑Basement/lio Plumbing, 7. If Business/Industry /Other: verify type # People tt Sinks # Commodes tt Showers # Urinals # llaLor Coolers IF FOODSERVICE: 0Seats Estimated Water Usage (gallons par day) 8. Type of water supply: VJCounty/City t 4T 1 ❑ Community 9. Do you anticipate additions or expansions of the facility this system is iIItended to serve? ❑Yes ❑-11-0— If ycs,11-hat type? ***1A1P0R7i1NY%**CLI LNTS AI UST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED *1;1.011', Either n PLAT or SITE PLAN A/U.STBBSU/1M=ED by the client with'rl(IS APPLICATION. Property Dinlcnsions: ( a r_, ./ 1VIi1TE DIRECTIONS(from 10ochwille)to PROPER11%, Tax Office PIN: li 6to5 q-T q4 6D I AJn t-+ti. :t12 Q annP_r pc'� Property Address: Road Nainc Dethy)e-r Rd. Laf 4 9 City/Zip M o c,L5 t)i I ti A C- 77 U_r 77U_r If inn a Sub rovide information,as follows: Namc: Section: Block: Lot: 'Date honne corners flagged: 05 'I'liis is to certify that the information provided is correct to the best of my knowledge. I understand that any pernnft(s) issued hereafter arc subject to suspension or revocation,if the site plans or intended use change,or if file information submitted in this application is falsified or changed. I,also,(understand drat l am responsible for all charges hictnrred fraan oris application. I,hereby,give consent to the Authorized Representative of the Davic County Ilealtli Departunent to enter upon above described property located in Davic County and owned by to conduct all testing procedures as necessary to determine the site suitability. ,0 DA'I'1's 5 SI6NA'I'URE Oliri.l�}r�. Qa TIIIS AREA MAY BE USED FOR DIZIINVIN Ygfm SITE PLAN(Include all of the following: Existing and proposed property lines and dimensions, structures, s tb I nd septic locations). Site Revisit Charge - Dalc(s): Client Notification Date: EIIS: Sign given U 'Account No. 9 90` � J Revised DCIID(05/03 Invoice No. 45/ 7( ELZ o- 0 207 '9Z o-- SZ 256 87 246 - � 246