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200 Pepperstone Dr Lot 12 i�yt,t,,C. .Yy'...cF„cjd:rw7 C.r t. 6 A 7 j r'•s tw,f,r 3 1.� "f�"l> 4 2.LY° o..r++..,, j+.:' "'_r Y � 11 X1.. � V. ✓�C0 AUTHORIZATIOWN6 ,.;� 8 0 8 DAVIE C�UNTY HEALTH DEPARTMENT iEnvironmental Health Section PROPERTY INFORMATION Permittee`; Mr , P.O. Box 848 Name , s Mocksville,NC 27028 Subdivision Name: _. Phone#'336-751-8760 Directions to property: Section: Lot: /oL� AUTHORIZATION FOR WASTEWATER Tax Office PIN: SYSTEM CONSTRUCTION Road Name: **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.]9.00 Sewage Treatment and Disposal Systems) Q� ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH PECIALIST DATE ISSUED tDt.r/r'�`'# � cc�"4 M �r -a ye.,.I 'f.'( �St4'ro 3'1 ',.e-'• r yr§* f,:-' � -� � t.) - _..� _ti.:. ..;../��: :<•• � .,.. �.r•,.:>, !i 0 DAVIE CfOUNTY HEALTH DEPARTMENT 1 !0 IMPRO EMENT AND OPERATION"PERMITS PROPERTY INFORMATION Subdivision Name: Directions to-propel'ty: F 44� Section: Lot: EMPROV61ENT PERMIT Tax Office PIN:45 ctcn�J - /0� Road Name• ip• **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 CONSTRUCITON must be obtained from this Department prior to the coiistruction/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) - f- ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE — PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER ' ENVIRONMENTAL HEALTH SPECIALIST, DATE ISS D. SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION:BUILDING TYPE "#BEDROOMS '�' #BATHS_ `�#OCCUPANTS GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE /3 U TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD)IFd4 NEW SITE 1/ REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE 1/�1P— GAL. PUMP TANK GAL. TRENCH WIDTH / ROCK DEPTH _ LINEAR FT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT ,. "CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DE RIM NT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M.OR 1:00 1:30 P.M.ON THE DAY OF IN TALL TION. EPHONE#IS (336)751-8760. 09 OPERATION PERMIT SYSTEM INST LED Y: Z9AUTHORIZATION NO. OPERATION PERMIT BY:• wcl� DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 05196(Revised) APPLCATION FOR 81-FE EVALUATION/IMPROVEMENT PERINIT do ATC Davie County Health Department Ent iroamenfa/Hea/th SetWon 10y P.O. Box 88/210 Hospital Street OV 2 4 Mockaville, NC 27028 (336)751-8760 ENVIRONMENTAL HEALTH DAVIE COUNTY ***ZNP0RTANT*** THIS APPLICATION CANNOT BE PJW SSED UNLESS ALL THE REQUIRED IMFORMATION IS PROVIDED.. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed / Contact person r r c Mailing Address Vrn Ile Y Rome phone n�LLIwO City/State/Zip i / e 21' Business phone 2. !tame on Permit/Arc if Different than Above Mailing Address City/state/Zip 3. Application For: (] Site Evaluation (9/Improvement Permit/ATC Bath 4. system to service: Lit"House 11 Mobile Home 11 Business 11 Industry 0 Other S. If Residence: # People # Bedrooms _:�F # Bathrooms 0Dishwasher 0 Garbage Disposal J'Rashing Machine q Basement/Pluabing 0 Basement/No plumbing 6. If Business/Industry/other: specify type # people # sinks # Coa®odes # showers # Urinals # Nater Coolers IP FOODSERVICE: I( Seats Estimated crater Usage (gallons per day) 7. Type of water supply: 01"Zounty/City 0 well 0 Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve! 0 Yes No If yes,what type. ***IMP0RTANP**CLIENTS AtUSTCOMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PIAT or SITE PLAN bIUST BESURWI TED by the client with THIS APPLICATION. Property Dimensions: lad 1C ;�-3 D WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: # J�B��o - 6�— D��vDOP/ 60 / id OA4h yk Q¢� rAAA- Property Address: Road Name City/Zip pg If in a Subdivision provide information,as follows: Name: Xe w, Section: 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 responsiblefor all charges incurred front this appU a dom 1,hereby,give consent to the Authorized Representative of the Da ie Coun H th 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 suitability. DATE �l_ ;,I �— �X SIGNATURE &clude THIS AREA MAY BE USED FOR DRAWING YOUR SITE P l of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Account No. Revised DCHD(07/98) Invoice No. 3 i - Pubuc Aav*4. _ 3 8l 32104a • 302.Sr . s 82ya`07T Ce D43q ly Utility 1 M► lO x ^ _ n o o 0 4 40 N ci jon �0N lo � 0„ W 5 1,50%1 5 , 270.05 N 84.28'4g" 127.55' N 29 O o 0 O '9 Og�3g►� �' Z 9 270.01 wCLN q z i v © (P- O v m � o 112'o OC I I / vtnvnt I I I 1t 5' S ,;ry = 1135•pO, Oto' �� *TO _ 53 p E p � PUe�-Io 1 / i271° .�O_ N 7g 4 112'15 Utility t /'N ca job.7 Cw r 151 tt7. o p N t- w N o, 0 3 Ck o m to `3 i S 8 . 148" cA a 14 0 0 1 .3 ao r o 0- o o 12 0 � lop a� � Cxiatin m i • �Camat o ro a 00' 112' .. . 58 05' 112.OV g 79 °6'11"8" 112.001 M641 .� N iW4470 w 1400, Cl ,0o