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217 Pepperstone Dr Lot 31 ALJTHORIZ4ION NO: 1601 DAVIE C UNTY HEALTH DEPARTMENT ;Environmental Health Section PROPERTY IINFORMATION Permttt.e's .�', P.O.Box 848 Ise J� �°� Name." t U�RL�� ►J/Mocksville,NC 27028 Subdivision Name: gsro w Ams ff„„� , Phone# 336-751-8760 , Directions to property: Ry Oa1Jl� Section: Lot: �hh r AUTHORIZATION FOR �uJ Iti'/��I (;+/�� �`i.{"�►:� 'inr�+� WASTEWATER - '62'D_ _ "+ SYSTEM CONSTRUCTION ' Tax Office PIN:# 65' 3tf%2, 1�. Road Namoff.e: " '�"os Ci. Zip: **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building-Pem-�its.This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits (In compliance with Article l 1 of G.S.Chapter 130A,Wastewater.Systems,Section.1900 Sewage Treatment and Disposal Systems) j G ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION C7L31 IS VALID FOR A PERIOD OF.FIVE YEARS. — M EPW 0 M HEALTH SP CIA6S DATE 1 SUE DAME O.UNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION.PERMITS PROPERTY INFORMATION Perls j Subdivision Name.' t E gsrom6 [f..45, Directions to property: .� �'J '� ',*.)>Jf..4 Section: Lot: IMPROVEMENT f t.:`n.� i i''n� L; 4 r. .t;�� ,i' PERMIT Tax Office PIN:#` ] i ` + Road-Name: = 1'"S 'r") Zip: 7 A ° **NOTE**.This Improvement Permit DOES NOT authorize the constniction'or installation 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. Ont 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 ENVIRON E TAL"IIEALTH SPECIALIST DA-- SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS 3 #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes 'No COMMERCIAL SPECIFICATION: FACILITY TYPE' #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT sIzE 133/- E WATER SUPPLY C . t� DESIGN WASTEWATER FLOW(GPD) aco NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZEQ�C'AL. PUMP TANK GAL. TRENCH WIDTH 36 ROCK DEPTH LINEAR FT. 0 OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: I tJST�Uc%lil C�JTDIJQ :Ut�EP lO 0�r Ww->zYu,46,� IMPROVEMENT PERMIT LAY UT 1�0Q 100 \� r-agar "CONTACT A REPRESENTATIVE OF THE DA COU EALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M.OR 1:00- . 0 P:M. THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. OPERATION PERMIT i l lop D ' 1 p D SYSTEM INSTALLED BY: AUTHORIZATION NO. / OPERATION PERMIT BY: /��Y 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 WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 051%(Revised) [AA U TION FORSITE EVALUATION/IMPROVEIHENT PERMIT&ATC "G ' 7Davie County Health Department u Environmental Health Section r P.O. Box 848/210 Hospital Street piYiROMMMALHEALTH Mocksville, NC 27028 QUV1ECOUN'T`— (336)751-8760 ***Il-1P0RTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. /> 1. Name to be Billed Contact Person re-e QO Mailing Address / QVa Home Phone /� Business Phone City/State/ZIP 70 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC V Both 4. System to Service: 911"House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms # Bathrooms Dishwasher ❑ Garbage Disposal �ashing Machine ❑ Basement/Plumbing 0 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: Li'County/City ❑ well ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes 17No ***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBAHTTED by the client with THIS APPLICATION. Property Dimensions: Tai Office PIN: # WRITE DIRECTIONS(from Mocksville)to PROPERTY: jJ' �1��—�� "��� Property Address: Road Name / �J�® 6r� J �. City/Zip �.7flA$ � aT - If in a Subdivision provide information,as follows: /Q� Name: Section: _� Block: Lot: 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. 1,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 suita itity. DATE 'S / / 1S SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE P AppHeation No. Invoice No. 7 Revised DCHD(07/91; 3 G 1,0 10 �� �= 5p gLGN ?e " oil TAX LOT f 3.0-1 1 ' 3: 3 x 7p 3 * �50Ca�•tnMt Ba, lDLCO BOOK 162 zo or N ®tN cv h N � ® 15 N a0 o �o to N m _ N O I z O S 1= 01 0 274' v - , 9„ e o e N � 12 8 45 ➢ g 4 „ e N 842 1� _ �� 1 - N1 Z /2 0 - _ N g4 28'+5 .46' to A � 232 41 - 133 3 Q 127.55' 1 29 -A A tv '1 r Z N to *io O 0 r • O O 'fes 0790g c� 3 co O S 1 - 1 O Z 21001 1� P -0 G14 15 O 1 13 �j S N a - O � p7 1� � A -110 x 70 SE_ -f 01- o� j VO lei 14 c�;Rve t 4 m - / O T � 3 '4 � 51 � 0 10 � VEMEN --+-� co - , A © - - o _ _ _ � 20 P C 21 �� A �� _ 2.7004 V E 95 6g, am•"T — ORI — tility Cp° — 00' p� Rr9T 8g8'3 U — 3 1 0 10; 50 p EP P E PUB�Ic o' _112.0 - 1271 112.0_ o �9 41,2gu a 112.0'— eo!•�"•"` ' _ 1 a N a •wry o.� _1t2.0� I12•p0 �� J O p 1 - � - c9 I `IItiw•tip 1P N N O1 Is 0 O• - - k1}0S 0 14 o O o R DOPg� m O c+ - A 0 n 3b u 3 ch o °o �9 0 7 �• 8d'S4'48" 14 0 � 19.37' N N OQo O O ' 6 111.9 a o 12 0 l O _ �. 3� 112.p0 ot xi ro�'1 �' 112 p0 EDITH QWN RUMMA 1Q •me 1 m 1120O� TAX LOT f 74 MA' 112p0` 121786ai �bk DEED BOOK 047 PAG p0' 79 02WW 15,31.09, Tot \q t` 5 S o 81�sr C 112.00, N sd'14'570 W ,4o.1r GRAPHIC SC 11t `LD 100 0 50 100 2c `12 hr .00 r MINIMUM BUILDING SCTBAGK 50' FRONT 30' REAR ( IN FEET ) 15' SIDE 1 1 inch = 100 M