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197 Pepperstone Dr Lot 33 �� �, � �.•�y. `�'�:,ff:.: .X�E..ay,L *�.ti 9:�k'+e.,. f:'^y+--'i,ti:.-''- i}�,t��g179;1v .", 9JXL RI7ATTJQN 90: DAVIE LINTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION 67 Permittee's i- + P.O. Box 848 • Name: �• 1t* �"'�u/ G' �� Mocksville,NC 27028 Subdivision Name: Lf' 'r� Phone# 336-751-8760 Directions to property: Section: Lot: 'S 'AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Tax Office PIN:, g �r Road Name: E �r ti'?. zip:./ **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 Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION A c�� ��// • - �j� IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED k'F',� C'T� � '`'` _ •"' cam,, e. ..18 9 8 DAVIE COUNTY HEALTH DEPARTMENT Vivo do IMPRO EMENT AND OPERATION PERMITS PROPERTY INFORMATION "Permittee's Name.,, -.;,�� t'a a < Subdivision NameAl r- j�la Directions to property: %! o r Section: Lot: + � r IMPROVEMENT PERMIT TaxOffice PIN:14- y ,� - a . Road Name: -.�'' -I'sr`rn,' tp: sy J'{' **NOTE**This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater systema 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) �ra � .***NOTICE***THIS PERMIT IS SUBJECT TO_REVOCATION IF SITE t �^ 'f• i�l/.� J �/"� PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION.BUILDING TYPE_)it #BEDROOMS 1#BATHS #OCCUPANTS GARBAGE DISPOSAL-Nes or No COMMERCIAL SPECIFICATION: FACILITY TYPE/ #PEOPLE #PEOPLE/SHIFT x#SEATS = INDUSTRIAL WASTE:Yes or No LOT SIZE e2ETYPE WATER SUPPLY DESIGN WASTEWATER.FLOW(GPD) ( NEW SITE � REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZEZ&j GAL. PUMP TANK GAL. TRENCH WIDTH�6 ROCK DEPTH f� LINEAR Fr. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT "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 OFIVSTALLATION.TELEPHONE#IS (336)751-8760. OPERATION PERMIT ~' SY M INSTALLED BY: lip. AUTHORIZATION NO. OPERATION PERMIT BY: DATE: J -*THE'ISSUANCE OF THIS OPERATION PERMIT SHALT,INDICATE THAT THE SYSTEK DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE... WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMPT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY.FOR ANY GIVEN PkRIOD OF TIME. DCHD 05/96(Revised) r D - k. APPUt'A]ION FOR SITE EVALLATION/IMPROVEMENT PERMIT - Davie County Health Department Envl>nnmentallfealffi SbWon P.O. Box 848/210 Hospital Streat Mocksville, VC 27028 JAN -8 1999 (336)751-9760 ***ndPCRTANT*** THIS APPLICATION CANNOT BB PROCB'SSED UNLESS TIS tI8.1 y INFORMATION IS PROVIDED. Refer to the INIMMATI0H RMARTIN for instructions. 1. Name to bre Billed!! caoas contact person Mailing Address L-Lm-&I&E ra, _ Esme Phone - !o - moi 2--7ro!8 city/State/zip Y_ .09KS✓i CIG lJL 27C.'2� Business Phone S tyv.el Z. Hams on Permit/ATC if Different than Above Mailing Address City/state/Zip 3. Application ror: U Site Evaluation V(Improv+ement Permit/ATC 0 Both 4. system to service: ISI House 0 Mobile Home U Business (] Industry 0 Other 5. IT Residence: . # People SPO&• ((� I Bedrooms 3 i Bathrooms :7-- `Q/Dishwasher 0 oazbage Disposal V/Washing Machine D Basement/Plumbing 0 Basement/No Plumbing B. If Business/Industry/other: specify type # People 0 sinks / Co�mtodes * shavers # Urinals Nater Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: county/City 0 Well 0 Conummiitjy e. Do you anticipate additions or expansions of the facility this system Is intended to serve? 0 Yes lYlHo If yes,what type. ***IMPORTANT***CLIENTS JIUSTCVAIPLEM THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITIED b j the client with THIS APPLICATION. Property Dimensions: 135,�(=X x'/1.79 Ibn.a ���?3.� WRITE DIRECTIONS(from Mocksvllle)to PROPERTY: Tax Office PIN: # 5��4—�5—��9�(,r�oo-P) Nw. �o1 Nva l� l►T ©,.1 Dz►�.�� . Property Address: Road Name POPrSm&r. DR, Cityinp M o CXS v%Ll 5 1J C— ©N ErT If In a Subdivision provide Information,as follows: Name: Section: Block: Lot: -3 3 Date Property Flagged: This Is to certify that the information provided Is correct to the best or cry knowledge. I understand that any permits) 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 falsilled or chouged. 1,also,undnstand that l am responsible for al!chxgesincurred from this appUcad n. 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 procedure as necessary to determine the site su DATE /-8-9 5 SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN elude all of the following: Eilstiug and proposed property lines and dimensions, structures, setbacks, and septic locations). Account No. oS Revised DCHD(07198) Invoice No. �0� - i f L 83.1r QANN1 02401- R RpA �y S 81 J2b4„ PUBLIC I � 3 15 1X5_46' 401.9' 20' pq,,*Q ' 11h11ty C�^�nt 114'S4, GENERAL NOTCS-. 0 LOTS SERVED BY: DAVIE CC 3 0 PRIVATE INDIVIDUAL SEPTIC 0 NO DRIVEWAYS SHALL d$ LG Id n - OP A STREET RIGHT OF WA� A n 3 0 ZONED R-A N do4 nn n� 0 2675 LINEAR FEET OF NEW k n �O1- � o O ° a ce'I' MINIMUM 5UIL DING i 49 0) o I. 0 O 501 FRONT or I 30' REAR 15' SIDE 118.,54, 17548, 114.561 S 8p.29'Sg,� 9707' e 1Q0 00, 121.48 10000' SHEET 1 Q P PPERSTONEII' I � E SUB—DIVISI`: 3 4a + t 3 ° a c° OWNER—DEVEL z �* CLAUDE R. HOR 190 NORTH MAIN t MOCKSVILLE, N. C. yis cO�m�n TELEPHONE: 704/ 8 g 81' a' a .F7.5 0 PU8LiC C3 — C4 — — C5 .wry BEING TAX LOT 99 / 00' 0 �e RECORDED IN DEED BOOK CURVE # 2 - _ q ig_88� N �e 41'29�� E CLARKSVILLE T0) — ca _ _c7 _ _ _ce _ _ ` o •a DAVIE COUNTY Q I 1p a • O� 3� �s -IV 1 7V �(d Jo- �54'4aN wl,' 1���' SURVEYED NOVEMB // g�' s 86 '9.37/4' BY KENNETH L. 0 3 ; �5.7s" u O R.L.S. 255 m - // / 0 12 0 o co o nt t o N ei 1 r o C*M*t 3 TOTAL AREA = 45.01 1 �� `'� O • N O ° A �O ° / / N N N �%88.84' S 86.14'57"1E GUPTON-FOSTER AS ENGINEERS—PLANNERS— 2200 SILAS CREEK H SUITE 28 63.9 3> ,�o.pO' >>24 WINSTON—SALEM, N. X38?s38i�1 — 1s 5 79 4129" W TAX LOBROWN 4 MAP RUMMAGE TELEPHONE: 910-7 _ — E5DEED BOOK 47 PAGE 206 tka NOTE IRON PINS PLACED AT ALL LOT CORNERS UNLESS OTHERWISE NOTED. NOTE: NO GEODETIC r'()NTROL MONUMENTS rOUND WITHIN 2000 FEET. i