137 Pepperstone Dr Lot 39 Pat
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 989900353 Tax PIN/EH#: 5820-55-8318
Billed To: David Cozart Subdivision Info: Pepperstone Lot#39
Reference Name: Location/Address: Pepperstone Drive-27028
Proposed Facility: Residence Property Size: see map
ATC Number: 2676
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 WASTEWATEYCJDNSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature:
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 Secti .1900"Sewage Treatment and
Disposal Systems,"but shall in NO WAY be taken as a guarantee that e t will function satisfactorily for any
given period of time.
Septic System Installed By:
Environmental Health Specialist's Signature: Date:
DCHD 05/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 989900353 Tax PIN/EH M 5820-55-8318
Billed To: David Cozart Subdivision Info: Pepperstone Lot#39
Reference Name: Location/Address: Pepperstone Drive-27028
Proposed Facility: Residence Property Size: see map
ATC Number. 2676
**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 Qf' #Baths.S
Dishwasher. Garbage Disposal; Washing MachineO Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial
Waste: ElLot Size 3/,��c Type Water Supply C b Design Wastewater Flow(GPD) �� Site: New 0 Repair❑
System Specifications: Tank SizeGAL. Pump Tank GAL. Trench Width CT,/' "'Rock Depth ,6� Linear Ft.(V,O ,
Other:
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:_�--•�,S^dl
DCHD 05/99(Revised)
aM
U TION F011 SI FE EVALUATION/141PROVE&IENT Klliff.&A—C
Davie County Health Department
,AN 2 3 � Environmenta/Hea/thSectfon
P.O. Box 848/210 Hospital Street
ENVIRDNMENTAt HEALTH '.Mocksville, NC 27028
DAVIE COUNTY (336)751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer
to the
t'lhhe INFORMATION BULLETIN for instructions.
1. N �/�,
ame to be Billed 6 C^JCr& Contact Person
Mailing Address t t I ' l-p— Home Phone o- as�f O
City/State/ZIP (✓S b Business Phone G�8-
2. Name on Permit/ATC If Different than Above
Mailing Address City/State/Zip
3. Application For: ❑ Site Evaluation Jr Improvement Permit/ATC ❑ Both
4. system to service: E(
House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
i
S. If Residence: # People # Bedrooms _ # Bathrooms Z,5
V-D-1-hxasher eGarbage Disposal eWashing Machine d Basement/Plumbing U Basement/Ito Plumbing
6. If Business/Industry/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: 2-6ounty/City ❑ Well ❑ Community
e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes R-No
If yes,what type?
***IMPORTANT***CLIENTS MUSTCOMPLETETIIE REQUIRED PROPERTY INFORMATION REQUESTED' •'
BELOW. Either a PLAT or SITE PLAN MUST RESUBMITTED by the client with TIES APPLICATION.
Property Dimensions: �,--��yy��.,, n WRITE DIRECTIONS(frons Mocksville)to PROPERTY:
Tax Office PIN: #��y" �—�3� .�5
F3/30AOo3q
Property Address: Road Name
City/Zip
If in a Subdivision provide information,as follows:
Name: C �
Section: Block: Lot: 9Date Property Flagged: 1— � —0 l
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. I,also,understand that I am responsible for all charges incurred front
this application. I,hereby,give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine the site sui ability.
DATE O( SIGNAT
TRIS AREA MAY BE USED FOR DRAWING YOUR SITE P (Include all a following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Datc(s):
Client Notification Date:
EHS:
Account Noq2t7D
Revised DCHD(07/99) Invoice.No.