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208 Pepperstone Dr Lot 13 EG�Xf 1•�fTsd - '•�'i++.. }' y5'i o-�:•�i'v^•--�'a -..„=•i:¢y,,w,,t.v`�tJ.�a":.1:�i s sr '(`max:'"• t .}�a.;i i!.*t- �' 4+•}f . AUTHORgZ TION NO: 1672 DAVIE C UNTY HEALTH DEPARTMENT �. Environmental Health Section PROPERTY INFORMATION PermitteE's ''''� ''''nn' '++�-���'�i� ,Q �,��I�//�'� P.O.Box 848 Name; 'j, �/.d r S' l�//t�JPJ6 Mocksville,NC 27028 Subdivision Name: f,r %. / Phone# 336-751-8760 . Directions to property: G�i7il/ f Section: Lot: 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.1900 Sewage Treatment and Disposal Systems) ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.: < ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED ;r,, r.��yt A"e f° i v+ g'•,( !% •�a♦'na p„y. \c...�itiV i y ti M1r i, t ii -�, y yh�i1..}. .IV ;. DAVIE COUNTY.HEALTH DEPARTMENT, ' IMPROI 1EMENT AND OPERATION PERMITS PROPERTY INFORMATION �Permitte�'sJ r Namex' , :F '1 �' .C.TC,�/, PJ$� Subdivision Name: ,f. Directions to property: �`� Section: �+”. Lot: 45 IlVIPROVEMENT - C ' PERMTT Tax Office PIN:# - Road Name :"Lip: B': **NOTE**This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.Ari 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) / , r ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED., SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. 1. RESIDENTIAL SPECIFICATION:BUILDING TYPE V .#BEDROOMS #BATHS �_#OCCUPANTS GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION:FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT j *"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 T E DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. OPERATION PERMIT SY STALLED BY: i9 r AUTHORIZATION NO.]A�OPERATION PERMIT BY: DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE -7Z*Z WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 05/96(Revised) ` • ^ APPLICATION FOR SITE EVALUATION/IMPROVEMEmi PERMIT&A u • Davie County Health Department Environmenfa/Hea/th SOCHO17 ' P.O. Box 848/210 Hospital street u SEP 3 0 Mocksville, NC 27028 (336)751-8760 ENVIR�OANVIE CTA HEAM) ***IMPORTANT'*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFOMIATION BULLETIN for instructions. 1. Name to be Billed \J D CI C WS lle),*f=Byi C.DC7k Contact Berson Rq C?,5 w5 Mailing Address "-/0/ EL MoRC PJ . nome Phone 3&-yr12--7G/S city/state/ZIP 7vZ8 Business Phone S ikM F 2. Name on Permit/ASC if Different than Above Hailing Address City/state/zip 3. Application For: ❑ Site Evaluation �Iaiprovement Permit/ATC ❑ Both 4. system to service: House 0 Mobile Home ❑ Business 0 Industry ❑ Other eG• 5. If Residence: # People e-NOLLSG # Bedrooms # Bathrooms 2- Dishwasher ❑ Garbage Disposal mashing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: specify type # People # sinks # Commodes # showers # Urinals # mater Coolers Ir FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City ❑ well ❑ Community S. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes XNo If yes,what type? ***IMPORTANT'**CLIENTS AIUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN AIUST BESUBAIITTED by the client with THIS APPLICATION. Property Dimensions: .11-4 X Z 71) X/17- X Z 70 WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: # S8:;Lo -6 4-- 7q ;;!-S /,,000-P U S fl wu (2o ( Npg-rt+-LA pp RoAr y tnif, Property Address: Road Name Pew-iERS-Mti DK r2 City/Zip 1q 0C,kS Y,`1•1-�' /Vc' leo A-3�, - E Rs-r ki,i R k T 1Ui If in a Subdivision provide information,as follows: &P4&-157D J 0rZ , /-OT 13 a� Name: Section: Block: A Lot: ( 3 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 ibi ih. DATE 9_3011 SIGNATURE 7 THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN/(Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). L/7' Y r� �0 -►�busE a Account No. Revised DCHD( 7/98) i Invoice No. WIE c0lJ m mmm ornmL C�NTCRLIN'L' CLISM DATA CURVe 0 5 CURVE / 4 A a 14'46'05" A • 16'30'48" R - 347.65' R - 689.15' suC T - 46.004 T - 100.001 fwd L a 89.60" L - 188.61' s 81 32„048 e —— 3O2.SW 412 '2 ab7• SR — �. �.{3q 1y Utility ea a`—— _— , _ 20_o.aa csa s 3 I A Io 3 3 10 x r G2.60 SIGN 1?�s Or '♦ _ _ 70 g`a F X50 Ga�rt+M1 6 e8+ C >> _ f, 0 1D - a h to N 0(10 x 70 5E @4 ol O 412, 10 to) N 1.0 (v Q N N O 0 1679 Z m N 5 78 _ 270,05' S �= iD " m m1 V N 84'28'45" e N 84'28'45 N c,� 1 = `;41�29N e 133.46' �' < N 79 10 z 127.55'.. 29 K 232.41' � n o 0 z o 0 5 '�9 09,39n w 270 Q1v !,o OI 3 ° cis ? #p� 1� QI10 x 70 SL- 1., m �� o �o lie, 10 o �O Y. — �` p vEMENT 1 n — — p p0' l t 20' A 27 iEGsom `p— ` p - —g5.69, 0 15 t35. 0550.1 — pU9 868.59' 112.0'— 127.1 ( o41'29 112.0��-- q N 79 u t 112.00'— ta��m�tt ag to O' o �-- I91q'1 �` 18 O 01 O v o aSJ 1© ou � 0 _ �� � a o•1 �` 16 0 � � n . 015 n i 311-7 rag j6-r5414816 19.571J w o 14 0 n p7 O� 12 O m n 112.00' ro A = 112.00' 112.00' E1 n 112•p0TA 1217 86 1 k b DE 58.05' e 112.00' S 78 41'29„ W 1531.09 Total1 p,� 5 p6'11'ib" 112.00' 14O'T GRAPHIC SC ,00 o so ,00 zc MINIMUM DLILDING SI'TDACK 50' FRONT 30' ROAR IN FES, 15' SIDLI 1 1 inch = 100 M