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106 Pepperstone Dr Lot 1 DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990003662 Tax PIN/EH#: 5820-55-3318.01 PE Billed To: Pilcher Enterprises Subdivision Info: Pepperston Acres Lot#01 Reference Name: Location/Address: Danner Road-27028 Proposed Facility Residence Prooerty Size: see ma As stated in 15A NCAC 18A.1969(5) ATC Number: 4126 acceptedSystems 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 Tr ent and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONS N IS ID FOR A PERIOD OF FIVE YEARS. 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. t •is 1 -�- ' /4 _..._ . Septic System Installed By: `fes J"- Environmental Health Specialist's Signature: Date: 1 /710-5 DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section . P.O.Boz 848/210 Hospital Street 17- Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003662 Tax PIN/EH M 5820-55-3318.01 PE Billed To: Pilcher Enterprises Subdivision Info: Pepperston Acres Lot#01 Reference Name: Location/Address: Danner Road-27028 Proposed Facility Residence Property Size: see map ATC Number: 4126 **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 TypeOW #People #Bedrooms s�L #Baths Dishwasher: 12""" Garbage Disposal: ❑ Washing Machine: 2"' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste:❑ Lot Size®-% 4�' Type Water Supply V?Design Wastewater Flow(GPD) Site: New 21/Repair❑ System Specifications: Tank Size bO GAL. Pump Tank GAL. Trench Width � Rock Depth !� & Linear Ft. Other: 4 -j;>"ZrwynoJ BD->�S . NT 2�/o 1—'vLXmoJ SxE� -a- Required Site Modifications/Conditions: CsD j tole, F-a& c ( ca:4)Zz'�" id � ey lliz IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)W 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.**** J r- 3 3(0 �c-Tills P- ►IS0-1> P, tr Gat CR- Environmental QEnvironmental Health Specialist's Signature: Date: DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003662 Tax PIN/EH#: 5820-55-3318.01 PE Billed To: Pilcher Enterprises Subdivision Info: Pepperston Acres Lot#01 Reference Name: Location/Address: Danner Road-27028 Proposed Facility Residence Property Size: see map ATC Number: 4126 **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 11- #People #Bedrooms #Baths Z Dishwasher: Garbage Disposal: ❑ Washing Machine:C?'*- Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial)Specification: Facility Type #People #People/Shift #Seats Industrial Waste:❑ Lot Size c./.p Type Water Supply Design Wastewater Flow(GPD)SjD Site: New r2r Repair❑ System Specifications: Tank Size 1=GAL. Pump Tank GAL. Trench Width c:�Z," Rock Depth 1 2�' Linear Ft.? • As stated in 15A NCAC 18A.1969(5) Other: accepted Systems may alsp be used I Required Site Modifications/Conditions: ��� - OVACzn' �' --0 1e� or-F- IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER, RISER(S)IF 6 K 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.**** \ M I/J, a N L Environmental Health Specialist's Signature: ate: DCHD 05/99(Revised) ECSC 0 �1 [ APPUCATION FOR SITE EVAU)AHON/IMPROVEM MIT&ATC Davie County Health Departure JUN 2 72005 Environmental Health Sectio P.O. Boz 848/210 Hospital St.—set Mocksville, NC 27028 EWRONMENTAL HEWN (336)751-8760 . DAVIECOUNTY ***nWORTAN?*** THIS APPLICATION CANNOT BE PROC`.ESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Nams to be billed pdLa /�++ /�riScS T-OC, Contact PersonJonA4kyin r' /jl� !failing Address q V et-7 lV r &o!e K 2 p c(. Some Phone J 91 .3 26 g City/state/Zip/"laucsv'J)L "C- 27028 business Phone 336" 3`/S -U3Sl� 2. Noma on Permit/ATC it Different than Above Hailing Address City/state/Zip 3. Applioation For: ❑ Site Evaluation Improvement Permit/ATC 'R Both 4, sy■test to servicer 13,11ouso ❑ Mobile Home ❑ Business ❑ Industry ❑ Other s. It Residence: # People i Bedrooms 3 f Bathrooms �- Dishwasher O Garbage Disposal ik Washing Machine O basement/Plumbing O basesent/No Plumbing 6. Zf business/Industry/other: specify type # People / sinks 6 Commodes # showers # urinals i Mater Coolers Ir 8'OODSRRVIC8: # Seats Estimated Water Usage (gallons per day) T. Type of water supply: County/city ❑ Well ❑ Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes IkNo If yes,what type? ***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESVBMITTED by the client with THIS APPLICATION. Property Dimensions: I���l 301)X S `(� 7 x 1 a- WRITE DIRECTIONS(from MockrAlle)to PROPERTY: Tax Office PIN: # 5-� 2D�`� 33( g 601 T° D a7)rlcr '2d or, R+ Property Address: Read Name -c!C � y-w— qa_ �° /cppe s4vru acre s or, R71 A �pPe Rs-c�e.f�•-c.. City/Zip artc� .... (,- e- 1 s f /of 0>-7 2F, If in a Subdivision provide Information,as follows: Name: P--gQcrs�Or\e �Acrts ' Section: Block: Lot: Date Property Flagged: C9- 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 for all charges incurred from this application. I,hereby,give consent to the Authorized Representative of the Davie Cunty Health Dep rtment I to enter upon above described property located In Davie County and owned v��_ V'z>k. to conduct all testing procedures as necessary to determine the site suitability. DATE �o' 2 2—,9 SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locatibus)., Site Revisit Charge ......... " . ? Date(s): Client Notification Date: EHS: -757-� - O a Account No. Revised DCHD(07/99) Invoice No. - Ar O .. VOS� '-' 0 DEPARTMENT.OF TRAMPOR'TATION L K:•NA CERTIFICATE OF APPROVAL BY THE PLANNM BOARD TTRS we wAs I DIVISION OF HIGHWAYS ° THE Ivw Ou"PL W*C BaW HEREBY AFPROVEB THE FM FLAT FOR THE � :. PROPOSED SUBDIVISION ROAD PETTERSTOW ACRES SUBUM 1Lw. DEPMRIRES 6 x CONSTRUCTION STANDARDS CERTIFICATION IxlTym'RE' APPROVED- .!!/.•�`. . G .. .... THIS THE . .I[ . . UAY OF. A, t DISTRICT ENGINEER (SIAtrE7ER'S`_T.+ DATE .... .. .. t• .".. o w NORTH CAROLINA—DAME COUNTY CHAIRMAN, COUNTY PLAN BOARD NORTH t 6 STATI=MENT OF OW I.P.SHIP AND DEDICATION JTATEMENT OF BUB-DI VISION 1 (wE HEREBY CERTIFY THAT I AAI WE ARE) T�OWNER(S) OF THE 10 CDOESCRNBED HEREON. WFRCH S LOCATED IN THF SUBDIVISION' I•F{ET*TNFTN �.- Fa STS+(. CERTIFY TI-AT 7NE JURISDICTION OF OWE COUNTY AND THAT 1 HEREBY ADOPT THIS SUBDIVISION ,�1 p PLAN WITH MY FREE CONSENT, ESTABLISHED MINIMUM BUILDWG SETBAGIC PROPERTY AS SHGWN ON THIS PIAT CREATES A SUBDIVISION OF LAND P4 -t LINES AND DEDICATE ALL STREET'S. ALLEYS. WALKS. PARKS AND OTHER SITES UNDER WHICH DAVE COUNTY HAS AN ORCVHANS OF AND. tSKXI AND EASEMENTS TO PUBLIC.OR PRIVATE USE AS NOTED. REC,HAND THIS WHICH REGULATES THESE PARCELS OF LAND. WITNESS nrt'HANG TttS DAY OFAPRIa- •1995. SIGNED DATE OWER • - REGISTERED LAND SURVEYOR SIGNEDREG. / L-2552 DATE cwmm CERTIFICATC OF APPROVAL OP PRIVATC t1ECLARATION OF ROAD DESIGN (ON-SITE)SEWAGE- DISP05AL SYSTEMS AN12 CONSTRUCTION: 1 HEREBY CERTIFY THAT THE DAVIE COUNTY HEALTH DEPARTMM INS EVALUATED THE SUBDIVISION EHTTIED' PEPFYRRSTONE ACRES' WITH I HEREBY DECLARE TMT, TO THE SESF OF TAY KIIOWLEDCE, THE NON-STATE RESPECT TO CRSERTA MLD CONDITIONS ESTABLISHED BY STATE LAN OR MAINTAINED ROAD(S) ALLOWW I"" ARTICLE NI OF THE DATE COUNTY PROMULGATED THEREUNDER AND THE SAME IS FOUND TO COMPLY WTTH SUCH SUSDMSIOH REGULATIONS ANO WHICH ARE A PART OF THIS SUBDMSION HAVE CIJIERYA AND CONDITIONS EXCEPT AS FOUND M SUCH EVALUATION. FCR BEEN DESIGNED AND (WILL 00 BUILT TR THE StAt" OS OF SAD R£CUlATK*L DETANS Of THIS EVALUATION ANO TCR (BATTATTONS SEE THE WRITTEN REPORT Ci 1 ALSO HEREBY DECLARE THAT ONCX:THE ROAD(S) IS CONSTRUCTED TO THE REQUIRED STANDARN. I WILL (NO LGNGER) BE RESPONSIBLE FOR MAINTENANCE FILE AT THE SAID DEPARTMENT. OF THESE P41MM - - HFOMR NOTICE- THIS CERIFICATE DOES NETT C V— i ii`' SAID A PERFO QR„IPPET7ILQE 'JAL LOTS IN SUB-DIVIDER' y_ DATE COUNTY HEATH OFFICIAL CCRTIFICATC OF APPROVAL OF - DAYIE! COUNTY PLANNING Q_PARTMLNT �'l '1 HEREBY CERTIFY THAT THE SUBDIVISION PLAT AS SHOWN HEREON HAS BEEN FOUND TO COMPLY WITH THE COUNTY- 90.99' SVBDMSIOH REGULAT10N+A WITH THE EXCEP" OF SUCH'. / -� 0. N 85'52'' 0 . . YAtTVAfICE'S F-ANY. AS.ARE NOTED IN THE MINUTES OF THE - .. - 77' 3 � liO•'3 PLMRANO BOARD AND THAT IT HAS BEEN APPROVED FOR 7? — RECORDING IN THE OFFICE OF THE REGISTER OF DEEDS. R IS HEREBY NOTED.THAT SUCH APPROVAL FOR RECORDATION DOES NOT /•O� B 1NICLUDE APPRCIAL TO NMALL AND UT(IZE SANITARY FAC'.IUTIES NOR � 0$ 2,��i'8�1� `S3, S DOES R INCLUDE APPROVAL FOR THE CONSTRUCTION OR OCCUPANCY OF BUILDINGS OR STRUCTURES.' - DATE �` . �-~ / �•"� �1 iy,G� � `TS, C? 5 kg.i0 4 P, a r/��� g•�`�. . ��� X�o CTOR. DAVIE COUNTY PLANNING ` . / ,T7� �I Fi 1 /ro /O v Z �.O Ory -4- lx p / D\ x i�p• A� _ j �T 41 ,F_ i _ X '7 ? o �. C:, /Y r O� 01,/8` er Fq�-4 .Y y � ,, ! SR3 Rte, 00. k � I 0 e N C 6 co CLAU12E R. 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