Just played a bit more and found that things were fine until I was driving through a city and got major stutter and freezing. Looking at the console I found that it all related to when long lists of sleepers were being spawned near me. Here is what I hope will show a 30 second freeze just to load up some nearby zombies, this happened continuously in the city.
2019-05-29T18:59:16 1215.325 INF Time: 16.03m FPS: 63.55 Heap: 3498.3MB Max: 4550.2MB Chunks: 242 CGO: 130 Ply: 1 Zom: 5 Ent: 10 (82) Items: 9 CO: 1 RSS: 6363.5MB
2019-05-29T18:59:16 1215.742 INF 976.7253 SleeperVolume -2120, 43, -382. Spawning at -2069, 45, -349, group 'sleeperHordeStageGS46', class zombieMoe, count 5
2019-05-29T18:59:17 1215.834 INF 976.8192 SleeperVolume -2120, 43, -382. Spawning at -2107, 45, -362, group 'sleeperHordeStageGS46', class zombieJoe, count 5
2019-05-29T18:59:17 1215.937 INF 976.9216 SleeperVolume -2120, 43, -382. Spawning at -2097, 44, -366, group 'sleeperHordeStageGS46', class zombieMoe, count 5
2019-05-29T18:59:17 1216.046 INF 977.03 SleeperVolume -2120, 43, -382. Spawning at -2085, 44, -369, group 'sleeperHordeStageGS46', class zombieDarlene, count 5
2019-05-29T18:59:17 1216.140 INF 977.124 SleeperVolume -2120, 43, -382. Spawning at -2095, 45, -335, group 'sleeperHordeStageGS46', class zombieUtilityWorker, count 5
2019-05-29T18:59:17 1216.251 INF 977.2278 SleeperVolume -2120, 43, -382. Spawning at -2068, 45, -373, group 'sleeperHordeStageGS46', class zombieMarlene, count 5
2019-05-29T18:59:17 1216.335 INF 977.3199 SleeperVolume -2120, 43, -382. Spawning at -2073, 44, -369, group 'sleeperHordeStageGS46', class zombieJoe, count 12
2019-05-29T18:59:17 1216.441 INF 977.425 SleeperVolume -2120, 43, -382. Spawning at -2073, 44, -334, group 'sleeperHordeStageGS46', class zombieYo, count 12
2019-05-29T18:59:22 1221.633 INF 982.1394 SleeperVolume -2123, 44, -475. Spawning at -2102, 45, -466, group 'ZombieGhostTownGroupGS1', class zombieMarlene, count 14
2019-05-29T18:59:22 1221.733 INF 982.2395 SleeperVolume -2123, 44, -475. Spawning at -2115, 46, -441, group 'ZombieGhostTownGroupGS1', class zombieSteveCrawler, count 14
2019-05-29T18:59:23 1221.839 INF 982.3455 SleeperVolume -2123, 44, -475. Spawning at -2087, 46, -468, group 'ZombieGhostTownGroupGS1', class zombieSteveCrawler, count 14
2019-05-29T18:59:23 1221.949 INF 982.4559 SleeperVolume -2123, 44, -475. Spawning at -2100, 46, -464, group 'ZombieGhostTownGroupGS1', class zombieJoe, count 14
2019-05-29T18:59:23 1222.034 INF 982.5411 SleeperVolume -2123, 44, -475. Spawning at -2092, 46, -468, group 'ZombieGhostTownGroupGS1', class zombieArlene, count 14
2019-05-29T18:59:23 1222.137 INF 982.6437 SleeperVolume -2123, 44, -475. Spawning at -2103, 50, -465, group 'ZombieGhostTownGroupGS1', class zombieSteveCrawler, count 14
2019-05-29T18:59:23 1222.244 INF 982.7437 SleeperVolume -2123, 44, -475. Spawning at -2103, 46, -441, group 'ZombieGhostTownGroupGS1', class zombieArlene, count 14
2019-05-29T18:59:23 1222.347 INF 982.8536 SleeperVolume -2123, 44, -475. Spawning at -2089, 46, -452, group 'ZombieGhostTownGroupGS1', class zombieOldTimer, count 19
2019-05-29T18:59:46 1245.735 INF VehicleManager Save
2019-05-29T18:59:47 1246.019 INF Time: 16.53m FPS: 62.67 Heap: 3616.4MB Max: 4550.2MB Chunks: 242 CGO: 160 Ply: 1 Zom: 10 Ent: 13 (118) Items: 17 CO: 1 RSS: 6394.9MB
Then I went to a POI and opened up a container and got a 3 minute freeze that resulted in my first death on this playthrough.
2019-05-29T19:03:47 1486.257 INF Time: 20.54m FPS: 52.37 Heap: 3889.5MB Max: 4550.2MB Chunks: 285 CGO: 185 Ply: 1 Zom: 31 Ent: 39 (164) Items: 25 CO: 8 RSS: 6367.1MB
2019-05-29T19:03:59 1498.299 INF UnloadUnusedAssets 20.20682
Unloading 3 Unused Serialized files (Serialized files now loaded: 5)
Unloading 31352 unused Assets to reduce memory usage. Loaded Objects now: 487262.
Total: 105179.517705 ms (FindLiveObjects: 37654.843017 ms CreateObjectMapping: 19.774217 ms MarkObjects: 65458.013409 ms DeleteObjects: 2046.886632 ms)
2019-05-29T19:06:03 1622.146 INF Time: 21.04m FPS: 36.79 Heap: 4003.1MB Max: 4550.2MB Chunks: 285 CGO: 186 Ply: 1 Zom: 31 Ent: 37 (165) Items: 25 CO: 8 RSS: 6287.9MB
2019-05-29T19:06:30 1649.755 INF GMSG: Player '¤Ninja¤' died
Notice that the UnloadUnusedAssets supposedly only took 2046ms, but actually froze my game for a full 3 minutes.
I also noticed that every time VehicleManagerSave runs, it stutters and freezes, which is every 2 minutes.
Here's the top of my output log showing my settings.