187 Pepperstone Dr Lot 34 .: y. rl,.i i•.-,..--: ^'^Y r':s -.. ...f. rR /. R..• � ,..y ...,..^.« �. -:Y�.. :k`y. S i`i'Yw:YY7 ".,�'i
='AUI'I&ORIZATION NO: 157-9rj DAVIE COUNTY HEALTH DEPARTMENT//-
Environmental Health Section PROPERTY INFORMATION
Pgfmittee's-�'� 4�/ ,/f ' P.O.Box 848
Name: d.! _� ,.�' Xattt. �k^11r , •�'
,� .. MOcksville,NC 27028 Subdivision Name: +'
Phone# 336-751-8760
Directions to property: Section: Lot:
O
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN:#
X197
Road Name iA &Zip:,0740
**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
ONMENT L ALTH SPECIALIST DATE ISSUED
DAVIE COUNTY HEALTH DEPARTMENT
ti
��'
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Pgmittee's
c /4-f
u �'
-Name: / !� .� f— F +, �„�' Subdivision Name: i r
r Directions to property:f�. Z✓ "r(f�'i i .-r - Section: - Lot:
� IMPROVEMENT -
-.,ir�✓Jr,;l .A&
PERMIT' Tax Office PIN:# !'',+`a
-0 197
Road Name
**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 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 I l'of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
/ ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR TIIE INTENDED USE CHANGE.YOUR WASTEWATER
NYIItONMENT IALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS L#BATHS C�e #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOTS TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD)IZFjl,,�'� -� D)j?Ko NEW SITE� REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
0 - r
f OTHER(7 /o4ix LAM / 001461-
REQUIRED
SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT � F �1��Et{jSERtS1 IF 6* BELOW FINISH? E
IS ? GRAD
RpPROVED�
oit8PDO
//�� '/'11,/x/ ■fff �
A00S6 �)/�// //11 d n
r (101
V
**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 OF INSTALTELEPHONE#IS(7(641 Y00 X QK.
J (336)751-8760
OPERATION PERMIT /
SYSTE ST D BY:
� 1
AUTHORIZATION NO. -1 OPERATION PERMIT BY: 94�e- )ATE:
**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 05/96(Revised)
PLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT do ATC
: a Davie County Health Department
EnvImmenfal MOM SWUM
P.O. Box 848/210 Hospital Street
Mocksville, HC 27028
(336)751-8760
MENTAL HEPETN _...-�+
t -- T11ZS APPLICATION CRIUM BS PROCESSED MUMBS ALL THE PZQVZTM
VM&TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Blame to be Billed �� f�mEBU�L(7e"7?S Contact Parson '/L'`7Z(2T/Z{�st�JS
Mailing Address 4101 ;CZ MOR[ /Zd- name Phone ti`1 2- 7 e'/ t?
city/state/zip MOCks �,t� Nt; oZ20 Zc'� �rasieseaa none S»-r►..r.�
2. Salm on Permit/ATC if Different than Above
Mailing Address C_1ty/state/Zip ty
a. Application Por: U Site Evaluation td Improvement Permit/ATC ❑ Both
4. system to Service: B'House ❑ Mobile-Home ❑ Business ❑ industry ❑ Other
s. If PAsidence: 9 people t# Bedrooms 3 4 Bathrooms a—
T(bishwasher q Ga age disposal .Y Nashina machine p Basement/Plumbing O Basement/so Plumbing
6. if Easiness/industry/c)ther: specify type / People # sinks
i Commodes t Showers # fJrinals # water Coolers
If FOODSERVICE: f Seats Estimated stater Osage (gaiions per day)
7. Typo of water supply: W/County/City ❑ stall 0 Coamounity
e. Do you anticipate additions or eipansion:of the facility thissystem is intended to serve! ❑Yes VN0
If yes,what type.
***IMPORTANT'** CLIENTS AIUSTCOMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBUITTED by the client with THIS APPLICATION.
Property Dimensions: /-90.X 7-13 x WRITS DIRECTIONS(from Mocksville)to PROPERTY:
Wt,
Tai Office PIN: # 58:LV las- 3:Z-e9 •004 qT ,7l�S }frvy 6O/ y'u,�ti Li -r D h,
�T
Property Add-e2a: Road Name ��1�FRS)w LAR. DAIJAIE-'Z RJ- R'19A7- ,00 � p�RSTDr1>r
City/Zip 'b+2_ LeT 31f od 1-!Fr -
U in a Subdivision provide information,as follows:
Name: f C—Pf>gytS-W M a
Section: Block: Lot: 34. Date Property Flagged:
This is to certify that the information provided U correct to the best of my keowledge. I understand that any permit(s)
Issued hereafter are subject to suspension or revocation,If the slit plans or Intended use change,or if the information
submitted in this application is falsified or changed I,also,tmda�dwd that I ant respmnsible for all choyes inured front
this appUcation. I,hereby,give consent to the Authorized Representative of the Davie County Health Department
to enter.apon above described propertylocated in Davie County and owned,by.
to conduct all testing procedures as necessary to determine the site sui
.DATE �J J 3.�' SIGNATUR>v
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the foAowing. 1L3isting and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Account No.
Revised DCHD(07/98) } ? moo; V Invoice No.
A