164 Pepperstone Dr Lot 8 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account M 989900649 Tax PIN/EH#: 5820-64-0989.08
Billed To: Anthony YoungerOocation/Address:
ubdivision Info: Pepperston Acres F3-13/Block A Lot
Reference Name: Todd Younger Pepperstone Drive-27028
Proposed Facility: Residence Property Size. 115 X 295.04
ATC Number. 2098
**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 1 I 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 &gE #People #Bedrooms #Baths
Dishwasher: Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply6-0f+) Design
Wastewater Flow(GPD)a�5n Site: Newt' Repair❑
System Specifications: Tank Size IWGAL. Pump Tank GAL. Trench Width Rock Depth Linear Ft.,
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 Specialists 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#: 5820-64-0989.08
Billed To: Anthony Younger Subdivision Info: Pepperston Acres F3-13/Block A Lot
Reference Name: Todd Younger Location/Address: Pepperstone Drive-27028
Proposed Facility: Residence Property Size: 115X295.04
ATC Number: 2098
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 WASTEWA STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: lIYJ�«'"`-- Date: : �C— 57?
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 ter 130A,Section.1900"Sewage Treatment and
Disposal Systems,"but shall in NO WAY be t en a that the system will function satisfactorily for any
given period of time.
j��roC
Septic System Installed By: /
Environmental Health Specialist's Signature: �W_ Date: ��}/�` 94
DCHD 05/99(Revised)
/ M
-'' APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&Alu
_ �Q Davie County Health Department O
"a �� Enviienmenfa/HealthSm on IN 2 9 1999
�%S��-PCX •0. Box 848/210 Hospital Street
6eqMockaville, NC 27028 ENVIRONMENTAL HEALTH
7�C1"�`( ���
(33 )751-8760 751-8760
/1-ff_s.(_ DAVIE COUNTY
***IIPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. game to be Billed 0—\VNNVOl AWA C�V tL�AE�. contact Parson ON
CVJLC,l�2
Mailing Address 1 LI, L-/175 C!�• S 7 • Home Phone l 33� 1 )5/- y/ 7 l
City/state/ZIP M"':;" tU �L z'70 Busins.s Phone Mia 1"7
-?4(-
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2. Name on Permit/ATC if Diffsrent than Above �CC-5 4
Mailing Address City state/Zip
Application lication For: ❑ Site Evaluation Improvement Permit/ATC ❑ Both 4. system to service: U/House ❑ Mobile Home ❑ Business -❑ Industry ❑ Other
5. If Residence: # People # Bedrooms / # Bathrooms
6/Dishwasher ❑ Garbage Disposal 9/washiaq Machine ❑ Basement/Plumbing ❑ 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)
z. Type of Nater supply: 93/County/City ❑ Well ❑ Communityy
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes 2-4/a
If yes,what type?
***IMPORTANT'***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions: ��S Y
Z7`.S.o WRITE DIRECTIONS(from Mockvlle)to PROPERTY: DOTax Office PIN: # 5'&2b -to - -0aio0V (OU ( - A_lG h / 0 d /D*n4Sk (
.
Qtppw.sd..+.11�
Property Address: Road Name _��wL&s' 11 <? /ei,�Ar�a S �2 A_rp
if
City/ZlPAb V5;' R 7707K _ L c,4 ren M 0/4
If In a Subdivision provide information,as follows:
Name: _P1R Qgz0 Sken k ` g. QS
�1 a
Section: r- 3-�3 Block: Lot: Date Property Flagged: 1-� ! 1
Ills 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 .
DAif, t0 - 22 ' / l alviaith i�tixL
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Inc e allWteollowing: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Date(s):
a
Client Notification Date:
0
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EHS:
Account No.
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Revised DCHD(07/99) h Invoice No. O�
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SIC SCALE CATHERINE BAKER 7362 �39u 3 .16' 1300✓. ti,2g" w 3321
200 400 TAX LOT t 73 MAP G-3 — J �'
DEED BOOK 36 PAGE 99 _ _ — 5,�NT_Fj41►
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= 100 ft. ,4oTE IRON PINS PLACED AT ALL LO;
NOTE NO GEODETIC CONTROL MONUM