282 Danner Road Lot 50 - -- 4b DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990003773 Tax PIN/EH#: 5820-65-7543
Billed To: S&S Construction Subdivision Info: Pepperstone Acres Lot#50
Reference Name: Location/Address: 282 Danner Road-27028
Proposed Facility Residence Property Size: .700 acres
ATC Number: 4247
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 CONSTRU/CTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: �li 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 satisfa ori for any
given period of time. � / /'�!.
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Septic System Installed By: ;5r
Environmental Health Specialist's Signator .
i Date:
DCHD 05/99(Revised)
. DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760 Fax#(336)751-8786
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990003773 Tax PIN/EH#: 5820-65-7543
Billed To: S &S Construction Subdivision Info: Pepperstone Acres Lot#50
Reference Name: Location/Address: 282 Danner Road-27028
Proposed Facility: Residence Property Size: .700 acres
ATC Number: 4247 Site Type: ❑New ❑Repair ❑Expansion
**NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A
Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat
or the intended use change.
Residential Specifications: #Bedrooms —3 #Bathrooms ) #People Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size Cc G r r 5 Type of Water Supply: BLounty/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow(GPD)36,0 Tank Size4d - AL.Pump Tank,4/ GAL.
Trench Width 3L Cf Max.Trench Depth 3(,� Rock Depth Q— Linear Ft. Sao
Site Modifications/Conditions/Other:
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30—9:30a.m.on the day of installation. Telephone#(336)751-8760.
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Environmental Health Specialist Date:
i
DCHD 11/06(Revised) �(e�'f
DAVIE COUNTY HEALTH DEPARTMENT Pd, `LZ' V-06-
Environmental Health Section �i-0- 2 -Z
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990003773 Tax PIN/EH M 5820-65-7543
Billed To: S&S Construction Subdivision Info: Pepperstone Acres Lot#50
Reference Name: Location/Address: 282 Danner Road-27028
Proposed Facility Residence Property Size: .700 acres
ATC Number: 4247
**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 #People #Bedrooms y #Baths
Dishwasher Garbage Disposal: ❑ Washing Machin Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply I Design Wastewater Flow(GPD) Site: New4!r Repair❑
System Specifications: Tank Sizef�LDGAL. Pump Tank GAL. Trench Width_ Rock Depth Linear FkZo
Other: As stated in 15A NCAC 18A.1969(5) i:��,r 411
acceptedSys ems 1 r / `/ /1
Required Site Modifications/Conditions: 3;(p `-I l`i g0 Ll
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6 u 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:
DCHD 05/99(Revised)
:IMFOIR11ATION
PPLICATION FOR SITE EVALUATION/IMPROVEM NT PERMIT&ATC
Davie County Health Department
? 2005Environmental Health Section P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
R (336)751-8760
ORTIINT*** TIIIS APPLICATION C1lNNOT Z1E PROCESSED UNLESS ALL THE RL'QUIRED
IS PROVIDED.. Refer to the INFOMIATION BULLETIN for instructions. t-
1. Name Lo be Billed i��► (.�'rlS� fuG �!r� (L' Contact Person - +v, 5+'h
Mailing Address Ilomo Phone S31D -IS i 1 S 3�
City/State/ZIP P�on ice i1[ J-?yc(p Business Phone 33 Tc 4 Iq �LL19
2. Name on Permit/ATC if Different than Above
Mailing Address 5e7 43,=e- "*Improvement
3. Application For: Site Evaluation y.l Improvement Permit/ATC ❑ Both
4. System to Service: 0—I1ouue ❑ Mobile Homo ❑ Business ❑ Industry ❑ Other
5. Typo system requested: Conventional ❑ conventional modified ❑ innovative I3acCepted
6. if Residence: it People ,/ fl Bedrooms 3, U Bathrooms
Mishwashor ❑Carbago Disposal ®Washing Machine ❑Basement/Plumbing ❑Basement/Ito Plumbing
7. If Business/Industry /Other: verify type # People it Sinks
I Commodes i) Showers 0 Urinals # WaL-or Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
S. Typo of water supply: 12—County/City ❑ Well ❑ Community
9. Do you anticipate additions or expansions Of the facility this system is intended t0 serve? ❑Yes "0
If yes,what type?
1*1.21PORTANT***CLIENTS dl USTCOAJPLETETIIE REQUIRED PROPERTY lNI�ORAIAZ'ION REQUESTED
IIELOIV. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
'31"`3 Y X35
Property Dimensions: WRITE DIRECTIONS(from 11•Iocksville)to PROPERTY:'
Tax Office PIN: fl No,rl i,, 4-c 'ha n n&, 12c1_.
Property Address: Road Namc ?�t� 3>:zrnec Qj JJrrna-r„ ;g of, J /64 4,
City/Zip M&cksv:llv 37c-28 ke le
If in a Subdivision provide information,as follows: afc-fyPP 90�% s/c,�a 1OX-111F
Namc: PO42ayc'5 k n At re S
Section: Blocla Lot: sO Date 1►omc corners flagged:
This is to certify that the information provided is correct to the best of my knowledge. I understand tI►at any pernlit(s)
issued hereafter are subject to suspension or revocation,if the site plaIls or intended nse change,or if the information
submitted in (his application is falsified or clanged. 1,also,wttlerstand that l ail responsible for all charges incarrell froul
this application. I,hereby,give consent to the Authorized Representative of the Davie County IIealth Department
to enter upon above described property located in Davie County and olvncd by
to conduct all testing procedures as necessary to determiuc IIIc site suitability.
DATE / /tiel 0)5— SIGNATURE
TIIIS AREA M.&Y BE USED FOR D11ANVING YOUR SITE PLAN(Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
,o Site Revisit Charge
1c: Com/ l Date(s):
r
Client Notification Date:
-76
Sign given "Account No. 7 ` 3
Revised DCIID(05/03 Invoice No.
��UP�a 59Z� ,
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ECIARE THAT. TO THE BEST O/Kf KNOWLEDGE,THE: SU13DMS10ft RE,
MON-STATE: I HEREBr CfA1�Y THAT.THE.Dewe COUNTt.HEALTH DEPN uiw VARWICFS, IE
S) A IDWED UNDER'ARTICLE W OF. HE DAVIE COUNTY`•• • . CIALUATED THE SUDOMSlON,ENTTTLO: PEPPERSTONE ACRES t;INM PLANNING"BOAR.
LATIONS AND WHICH'ARE A PART-AF THS SUBDIVWN HAVE RESPECT 1O:CRITERLA'ANp`CONQ(iIpNS ESTABItSHED.BY 57AT[LAW OR 5
ND;(1►Ml -BE)*Bl r4T•TO-TIE SLIHONRDS Of..SAO REGULATION.. PR XOJLGATEO IS FOUND.hf klpQt:NW 1FIfi SAME IS 71?:COkPIl`MffIH,SUCH, RECORDING'I!1 T
t,CLAhE.TIIAI ik1ZE TH�MQg1(S) B-OONSTRUGTED.TO THE".';. CRYTM AN0 t10NS:!%CEAT`eS.FOUNq itf,SiJC1;EYAtW71CN. iOR:, HEREBY N07ED
taS. t't4TitL (Np LONGER?.BE•RESPONSIBLE•fOR W*aENMIC&- D0 IN;LuOE APPR01
AILS'OF THIS•ERN UATIOM ANP.FOR:LIMITATIOW SEE 1'HE'.WRITTIDi REPORT ON
FILE AT THE SAID DEPARTMENT. DOES IT INCLUDI
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