156 Pepperstone Dr Lot 7 DAME COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 989900649 Tax PIN/EH#: 5820-55-9061.07
Billed To: Anthony Younger Subdivision Info: Pepperstone Acres F3-13 Block A Ld- 7
Reference Name: Todd Younger Location/Address: Pepperstone Drive-27028
Proposed Facility: Residence Property Size: 118.22 X 307.0
ATC Number: 2099
**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 ONt _ #People #Bedrooms #Baths _
Dishwasher: Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
1
Lot Size g p Type Water Supply Design Wastewater Flow(GPD) Site: New X Repair❑
System Specifications: Tank Size/O��'DGAL. Pump Tank GAL. Trench Width Rock Depth IQ" Linear Fta�D/
Other: / 41 � 2A,-
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:
DCHD 05/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 989900649 Tax PIN/EH#: 5820-55-9061.07
Billed To: Anthony Younger Subdivision Info: Pepperstone Acres F3-13 Block A Lot 7
Reference Name: Todd Younger Location/Address: Pepperstone Drive-27028
Proposed Facility: Residence Property Size: 118.22 X 307.0
ATC Number: 2099
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 WASTE7TE TRUCTIONO�IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: �`"� 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. h pter 130A,Section.1900"Sewage Treatment and
Disposal Systems,"but shall in NOWAY betaken as a ua t that the system will function satisfactorily for any
given period of time.
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Septic System Installed By:
Environmental Health Specialist's Signature: Date:
DCHD 05/99(Revised)
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC D L�
IF
o Davie County Health Department
—/A/0 Environmental Health Section JUN 2 9 1999
P.O. Box 848/210 Hospital Street
S: �-1 �p� Mocksville, NC 27028 ENVIRONMENTAL HEALTH
-�� � ��/�j 4 (336)751-8760
DAVIE COUNTY
el
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
r-.
1. Name to be Billed I` Contact person 'TZOlin,Ihc,o-I-
Home Phone
Mailing Address -7)-1�l�f 7
IL
city/state/ZIP .11IDct-1 1)►%A AC •.z122 AA Business Phone 33,1 90 5 -/9-TV,,
2. Name on Permit/ATC if Different than Above -7
Mailing Address City/State/Zip
3. Application For: ❑ Site Evaluation improvement Permit/ATC ❑ Both
4. System to Service: tTomHouse ❑ Mobile Home ❑ Business`. ❑ Industry ❑ Other
5. If Residence: # People �� # Bedrooms # Bathrooms
8'Diahwasher ❑ Garbage Disposal 9,4&-ahing Machine ❑ Basement/Plumbing ❑ Basement/No 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: Runty/City ❑ Well ❑ Community
S. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes E-90,
If yes;what type?
***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAIT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions: [ �. W 1( 3 07.OG WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Tax Office PIN: # - . 24•.SJ=10&l 47(ci
Property Address: Road Name �7 'Fe car S�u J. ��_ �`�/ /tnr �-� i� �a
14 t-Icf%Jc 0-
-City/Zip PIP Joy I'- s 7�a
If in a Subdivision provide information,as follows: a-1 P. 2'd b au Se
Name: Pula('--> )viC- Alr-y •S -VV
A
Section: F .3_r.� 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 responsible for all charges Incurred from
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 suitabili
DA'T'E C �� —`I SIGNATURE
1111S AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Inde all ofa ollowing: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Date(s)-
Client Notification Date:
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