272 Danner Road Lot 49 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990003773 Tax PIN/EH#: 5820-65-6513
Billed To: S&S Construction Subdivision Info: Pepperston Acres Lot#49
Reference Name: Location/Address: 272 Danner Road-27028
ATC Number: 4234
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 Trea ent and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CON N IS ALID FOR A PERIOD OF I YEARS.
Environmental Health Specialist's Signatur : Date: /'0F
CER CA
OF OMPLETION
**NOTE** The issuance of this Certificate of Comin 'tate the system described on Improvement/Operation Permit
has been installed in compliance with AG. .Chapter 130A,Section,,1900"Sewage Treatment and
Disposal Systems,"but shall in NO WAa guarantee that the system'will function satisfactorily for any
given period of time.
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I"d
Septic System Installed By: '"
Environmental Health Specialist's 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
IMPROVEMENT/OPERATION PERMIT
Account M 990003773 Tax PIN/EH#: 5820-65-6513
Billed To: S&S Construction Subdivision Info: Pepperston Acres Lot#49
Reference Name: Location/Address: 272 Danner Road-27028
Proposed Facility Residence Property Size: 220 x 150
**NOTE * I nis 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 11 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 -)+QZC #People #Bedrooms -3 #Baths :-
Dishwasher: 21"' Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type n #People #People/Shift #Seats Industrial Waste: ❑
Lot Size 30 CM�t2 Type Water Supply ►,rK Design Wastewater Flow(GPD) Site: New ET"—Repair❑
System Specifications: Tank Size IQQDGAL. Pump Tank GAL. Trench Width ��' Rock Depth 12- Linear Ft. ?
Other: 31�T Q 1 I�j�1-1 O.a5
Required Site Modifications/Conditions: lbZ-1- i-- of C-E�f Utf� !�' cS o4 Kj 1p'gr— W..U
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 Specialist's Signature: Date:
DCHD 05/99(Revised)
APPLICATION FOR SITE[VALUATION/161PROVEM NT PERMIT �' � C E E
Davie County Health Department
Environmental Hea/t/y Section
P.O. Box 848/210 Hospital Street OCT 1 -7 2005
Mocksville, NC 27028
(336)751-8760 EDMRONMENTALHEM
***IIFSPORTANT*** TIiIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE
INFORMTION IS PROVIDEDD. Refer to the INFORMATION BULLETIN for inatructions.
1. Dame to be Dilled S ( S �0!15�:Ott 1'OC�/� Contact Person Ti n-,
Mailing Address Ml!1 _JAr\ (/��rc)iiS - 0 � Home Phone(o 7S / �S L3�2
City/State/ZIP MotAll V,die 1 1 1 l 0176)--s Business Phone CuL�d/C5,
2. llama on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3.• Application For: ❑ Site Evaluation 1 Improvement Permit/ATC ❑ Both
a. System to Service: 13 House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. Typo system requested: 13 Conventional ❑ conventional modified ❑ innovative r3acCepted
6. if "Residenco: it People tt Bedrooms 1_ a Bathrooms
IZDishwashor ❑Garbago Disposal ®Washing Machine ❑Basement/Piumbing ❑Basemont/tio Plumbing
7. If Business/Industry /Other: verify type # People tt Sinks
it Commodes 9 Showors ¢ Urinals 0 Water Coolors
IF FOODSERVICE: ti Seats Estimated Water Usage (gallons per day)
0. Type of water supply: M County/City ❑ Well ❑ Community
9. Do you anticipate additions or eap.insions of the facility tills system is intended to serve? ❑Yes ®No
If yes,n•hat type?
***IAIP0RD1NT"**CLIENTS AI USTCOAIPLE?'L•THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. hither n PLAT or SITE PLAN AIU.ST IIE.SURAflTTED by the client with THIS APPLICATION.
Property Diniensions: Z2-0 X l5'0 WRITE DIRECTIONS(from Moclaville)to PROPERTY:*
Tax office PIN: li Y2-o os awy be I)an Aer red•
Property Address: Road Name 2- 72 ! amor Rd 1?n n P r- 2 Acv ra�r 3�/ r„n'>'P
Cily/Zip—A4r V,SJ,'ItP 172S- t"o
If in a Subdivision provide infornluation,as follows:
Section:�T Block: Lot: Daae Ironic corners flagged: i` y�
This is to certify that the information provided is correct to the best of my knowledge. I understand that any peru l(s)
issued hereafter arc subject to suspension or revocation,if the site plans or intended use change, or if the information
submitted in illis application is falsified or changed. I,also,utrnlerstand that I aun responsible for all charges incurred fraun
this application. I,hereby,give consent to the Authorized Representative of the Davic County IIcalth Departnicnt
to enter upon above described properly located in Davic County and otivned.by
to conduct all testing procedures as necessary to delcruine the site suitabiliq�. \
DATE Q 00 t- 0 SIGNATURE
THIS AREA MAY BE USED FOR DRANVING YOUR SITE PLAN(Inclu a all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
/I Site Revisit Charge
42' CL O P. :�f
�x ;y •k'j . Datc(s)
$�PC'�"'�'`"� S �0 1 IoS Client Notification Date:
Sign given ,Account No.
Revised llCIID (05/03 Invoice No. C-)
---- - IV IV'J1 LI JLWH +�" lJlbNC1 AI' ST�+T Llai c+ HCZEON HAS BEE
ECLARE THAT. TO THE.BE$[OF NK'K "
SUBDIVISION REGI
NOWLEDGE: THE NON-SUTE I HEREBY CfAT1FY TMAE THE DAVIE COUNTY HEALTH DEPARTMENT HAS VARIANCES. IF AN
S) ALLOWED UNDER AREA W OF.THE DAME COUNTY C:ALUATED THE SUBDIVISION DnTax--D" PEPPERSTOME ACRES WITH" PLANNING BWRD
tAT10NS AND 1A117ET ARE A PS OF THIS SUBDNISEG HAVE RESPECT TO'CRITERIA ANO`CONDITIONS ESTABLLSHED-BY STATE LAW OR RECORDUIG IN TH
ND. kE AI BUILT H TME STANDARDS OF SAaQ .70 THE'
- `. PNCAIULGIITED P*74 I!DER AND THE SANE IS FOUND:70.COMPLY WRH.SUCH
SCLARE 7NAT
ONCE THE B
CONST
RIICTED.
li0�u(S) 70
THE' -
. HEREBY NOTED TI
CRTTEILIA f T IS EVA1ONS E%CEPT i.3,FOUND IN SUCKC EVALUATKkL• FOR. IW;IIJDE APPROVA
M t'WILL (NQ LONGER) BC RESPOtISIBLE'FDR �IAWTFlIANC[ DETA0.S Of THIS EW LUATIOk ANP FOR LWATIONS SEE THE W ITTIEN.R°PCR( ON
FILE AT THE SMD DEPARTUENT. DOES R INCLUDE
OF BUILDNGB OR
WPORTANY'NOTICF'- THIS CERTIFTP�Tr IY1cc
SUB-DMDER r
CONSTTT n A'emwTOPd
- 'APPRUL Of u
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-
SAID SuBmisom Em
H-OF DATE
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DAX.;, . :. COVNTY HEALTH OFFICIAL
Qf!NTCRLINC GURVC DATA
CURVM +f 3- CURVE. IF 4
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