149 Pepperstone Dr Lot 38 ,ei,tir.. :.,:4
AUTHORIZATION NO:. . rJ DAVIE, COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee's. P.O.Box 848
Name:'
�(LG— - )�G�t�c;r;� IVlocksville,NC 27028' ' Subdivision Name:����z�� ' C�.•S
M.. .
f -\ Phone# 336-751-8760,
Directions to property:�11.E �t �cU� !� `1^ Section: l Lot:
p . n AUTHORIZATION FOR
ro u WASTEWATER . _ 377� r * Tax Office PIN:#SYTFMONSTRUTO
R71
oad Name:� �+r "rt r-. ip: 27v
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building-Permits.This Fonn/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits..
(In compliance with Article 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
y - ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS:'
�,: V O EN AL HEALT SP&ALIST'
3 1 8A DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION.
Pernuttce s"
Name, F* tr L l`, "��1.��r. d~t�,',t3 Subdivision Name !I F�
-r
Directions to property: t tm' 'f 1 Section: Lot:
''K
IMPROVEMENT
PERMITTax Office PIN:# .w
Road Name: . Zip;
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation 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)
j ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENV O (viENTAL HEALTH SPP51ALIST Dg I SUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
} , INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE1E#BEDROOMS '� #BATHS .G #OCCUPANTS GARBAGE DISPOSAL:Yesio�
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE JSS Y-2(' TYPE WATER SUPPLY 'M,&) DESIGN WASTEWATER FLOW(GPDA20 NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE LQPaGAL. PUMP TANK GAL: TRENCH WIDTH- (p I ROCK DEPTH 1� LINEAR FT.
OTHER I �ISTR IEDV It01-�
REQUIRED SITE MODIFICATIONS/CONDITIONS: �A�-1 &rZ (2,z,.3-to o�
fl o Z feu F
A rP'ex. W
IMPROVEMENT PERMIT LAYO +APPROVED EFFLUEirr FILTER* &RISER(S) IF 61' QELW FIIIISRED GRADE;
.*'"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(4M)W**?M?t
(335)752-8760
OPERATION PERMIT ^ ` -1
SYSTEM INSTALLED BY
V
314 MAN IL`��
V `L-UXr> is-zo
l�O �
AUTHORIZATION NO, _OPERATION PERMIT DATE: ID
C:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DES ED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96(Revised)
ktooA
�-� APPt1CAl10N F Davis County Health Department
�PERMIT �
Envir�vnmenta/Health Se+cHon
P.O. Box 848/210 Hospital street A R 237
Mockaville, NC 27028
(336)751-8760
EWIRONM
***ZNPORTANT*** THIS APPLICATION CANNOT 8E PROCESSED UNLESS
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
i. Name to be Billed le 5pv �j4f a contact person GJ p
Nailing Address 60 t d B'o X /D r� ,!� Name phone 'q/ O ^
city/state/ZIP IWACK.s',�[f��,e ,A� [ Business Phone
Z. Name on Permit/ASC if Different than Above
Nailing Address City/state/Lip
3. Application For: USite Evaluation ❑,Improvement Permit/ATC 0-Both
4. system to service: 9 House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
e. If Residence: # People # Bedrooms _ # Bathrooma
F-Sishwasher 0 Garbage Disposal 901*ashing Machine 0 Basement/Plumbing 0 Basement/No Plumbing
6. If Business/Industry/other: Specify type . # People # sinks
# Commodes # showers # Urinals # Nater Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: H County/City ❑ well ❑ Co==nity
9. Do you anticipate additions or expansions of the facility this system is intended to serve! ❑Yes irNo
If yes,what type.
***IMPDRTANT*** CLIENTS AIUSTCOAWLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN AIUST BESUBAH17ED by the client with THIS APPLICATION.
Property Dimensions: W-/ 3 6V 341 WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Tai Office PIN: #
Property Address: Road Name Q lah e-,Vt- l-'
City/Zip !rA hfJJ 7/� �e T o n
If in a Subdivision provide information,as follows:
Name: n �lal CA—
Section: l Block: Lot: Date Property Flagged:
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 ra ponslble for all charges lncuffedfrom
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 be
to conduct all testing procedures as necessary to determine the site suitability.
DATE 7 a3 ! SIGN TU
THIS AREA MAYBE USED FOR DRAWING YOUR P
d tic (include all of the following: Existing and proposed
c
property lines and dimensions, structures, setbacks, locations).
1EA1 z3
Account Na �/
Revised DCHD(07/98) Invoice No. 472
HE sum esm EMTTLED ' PEPPERSTOME PORES ' MRTH HEREON NAS BEEN FOUND TO COMPLY 3? J
CIOTEIM AND COIORKM ESTASUSMED BY STATE LAW ON SUS MS10M REMAATIONS FOR DAME COUNTY. "D'" B. THE 1 1 GQ
D TIEJIE AMM AND AE SATE RTH CiMOEM IS FOUND TO COMPLY NRH SUCH NO ,, AMD THAT TMS PIAT HAS 8 9 mw
3 COMMONS "CC" AS FOU4D M SUCH EYAU J AT10k FOR DAYIE COWRY BOOM OF aMMSS7OMQS FOR XWORDM N 10 C7 _ ---_-
TMS E FI'mA FOR LINT4T1 M SEE THE MIOTTBI REPORT ON THE OFFICE OF THE M91S7BN OF DEEDS OF DOW ODUWY-
SAID OrPNIITIMMBIt. * MO
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A P[]i1Q OR AF�PIMDML_aF••,••yam c"
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