235 Shadow Ln DAVIE COUNTY HEALTH DEPARTMENT "7�5����'SS�
Environmental Heaith Section /� ��ls v /
_ - • P.O.Boz 848/210 Hospital Street //�' � /
. �. . � Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001997 Tax PIN/EH#: 5776-78-2731
Billed To: Joanne Ragan Subdivision Info:
Reference Name: LocatioNAddress: Shadow Lane-27006
Proposed Facility: Residence Property Size: 7,8 acres
ATC Number: 2976
**NOTE**This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AiJTHORIZATION 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 #People .� #Bedrooms�� #Baths�
Dishwasher:� Garbage Disposal: � Washing Machine� Basement w/Plumbing: � BasementlNo Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply �iI/e// Design Wastewater Flow(GPD) C��� Site: New�Repair❑
System Specifications: Tank Size/�GAL. Pump Tank GAL. Trench Width��`Rock Depth /o� �Lineaz Ft. g(,�
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF G"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:3 . e a of installation. Telephone#is(336)751-87G0.****
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/ / Date: /� -�C�1 �
Environmental Health Specialist's Signature: ,
DCHD OS/99(Revised) .
DAVIE COUNTY HEALTH DEPARTMENT
' � •� • � Environmental Health Section
' r.o.Bog sasnio x�p���s��t
Mocksville,NC 27028
(33G)751-8760
Account #: 990001997 Tax PIN/EH#: 5776-78-2731
Billed To: Joanne Ragan Subdivision info:
Reference Name: LocatioNAddress: Shadow Lane-27006
Pro osed Facilit : Residence Pro ert Size: 7.8 acres
ATC Number: 2976
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLJST BE ISSLTED 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 Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWAT CONSTRUCTION IS VALID OR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: . �Date: �0 ��-�r
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on ImprovemendOperation Permit
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 guazantee that the system will function satisfactorily for any
given period of time. �
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Septic System Installed By: c3 `" l ,—� �' 7
Environmental Health Specialist's Signature: (�V_�f � Date: � -��
DCHD OS/99(Revised)
t . . -�.� - APPLICA710N FUR SITE EVALUA710N/1MPIi0VER9ENT PEIi�91T&/lTC �
<
. ' Davie County Health Department
" (� Environmenta/Hea/t/�5ection
O � � �2, � � l5 P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
Crn � 7 ,�0�' (336)751-8760
�7G1"
***IMPORT T** THIS APPLICATION CAPTNOT BE PROGESSED UNLESS �ALL TH� I2�QU2R�D
� �111R'^TNFOE2MATION IS fPROVIDED. Refer to the INFOF2Mb�TION BULL�TIN for instructions. !
__...._.._:_:.:_:�,.,.. — �� _
~� 1. Name to bo IIilled � h �iL , � ContacC Porso
p2 ----____ ---- —
. Mailinq Iuldress \ � 17 � I � �� Homo Phona ,3 a�� '�2,�-�1 ���O
City/State/ZIP ��,�( �(��g �� ,�-'�OU��--IIusiness Phone �j3� —���-��dv 1�����
2. Name on Permi.t/ATC if Different than Above •
Mailinq ]1+cldress city/state/zip
3. Application For: ❑ Site Evaluation �O�,Improvement Permit/ATC� II Both
a. system to service: �House ❑ Mobile Iiome ❑ Business f_1 Industry Il Other
5. If Residence: # People� �, # Bedrooms �_ N Bathrooms �
�Dishxasher U Garbaqe Disposal . I lashing Machine LI Basement/Plumbing I I IIasement/Nu Plumbing
/ � �
6. Zf Business/Eadustry/Other: Specify type # People A Sinks
d Commodes # Showers # Urinals II Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (galions per day>
7. Type of water supply: ❑ County/City �ell LI Community
e. Do you anticipatc additions or cxpunsions of ihc facility tl�is systcm is intcadcd to scrvc? 1-1 Ycs �u
lf ycs,wt�at typc?
***Id1PORTi1NT***CLIENTS NiUSTCOd1PLLTETHE RLQUIRGD PROPLRTY INFOIUVIAI'ION IiGQU1,S'I'L:D
I3ELOW. Either a PLAT or S1TE PLAN t�1UST BESUB1�il7TED b,y tlic clicnt witl�TIIIS API'LICATION.
Property Dimcnsions: / • � �j( �{�_. WRITL llIRLCI'IONS(from I19ocicsvilic) tu PKO!'I;K'1'1': `
Tax Officc PIN: #S'7�1 (0 �� a'13) (��1 e c�.o� � �3 01 - �'w,h n�-
Property Address: Road Namc S h 0.O�OW I�G�.Aa. O`� �� 1 . .Y,t,�.�- 01r��I VP,t(h�W�'1J
City/Zip (,il OC t��'(, h C � �Q ��" Dr� �22TlJV� , �P �-�' 0 h
If in a Subdivision providc information,as follo�vs: !�( �l G..- �I- .� �G►��C f1r!Gl��
Namc: �W (rOCt C� s�d dW 1-h t,�.�r�
�••�� �v slr.�p �+ �-�.l��c�1
Scctiun: Block: Lot: . Datc Pruperty rlabecd: �°�`�Sc� A�'
�,������
This is to ccrtify t6at thc information providcd is corrcct to tl�c bcst of my Icno�vlcdgc. I undcrstand ILat any permit(s)
issucd hcrcaCtcr are subjcct to suspcnsion or revocation,iC thc sitc plans or i�ilcndc� usc chan�;c,or if lhc infor�u:�tion ����
submittcd in tl�is application is falsificd or cl�angccL 1, alsu,«ndcrstun�!l/tat!am respnnsiLlc for a!!c/rurges inc•r�rrcJ frnn�r�„ h�(�
.._�f,
r�,�s ar�!«ar�o,:. I, I�crcby,givc conscnt to tlic Authorizcd Rc�rescntativc of thc Davic County Flcalll� Dcpartmcul
to cntcr upon abovc dcscribed property locatcd in Davic County and o�ti cd by ______. _ _�,�b�
to conduct all tcst ng procc ures as ncccssary to dctcrminc ' c sui bility. "''Y;
�Cna�l- �S
llATC � O� S[GNATU �(„6�
�OW�e� !-�}'
THIS AREA MAY BE USED FOR DRAWING YOUR SIT� L (Includc atl of thc following: Cxisting aud proLo�c��h
property lincs and dimcnsions, structures, sctbacks, and pt' locations). �%t �
Sitc ltcvisit Cl�ar�;c
Datc(s):
��.., fLC_a-� _ Clicnt Notification Dutc:
�HS:
Account No. ! �
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Rcviscd DCHD(07/99) [nvoicc No. �
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•nE vn�••i�:on. �nn� �rv• n��o M �1 i _ " ' . 1 : .. - � -
. � � � ` DAVIE COUNTY HEALTH DEPARTMENT �
;
' .� � IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION f�� v'�
' .. _ _.
'NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a :.
Sanitary Sewage S stems 4 P,ermit Numb9r
Name �o At� 'N e_ � A`�'P� Date O '9 I �' N� � � 9 �
Location y U�� `C �1J�.\'�1 �W'��/ `,. i- � 1 ���c�, b''l�S N C,. �;�� � 2 . '
�
�� �_ � � U t,s � �, � �u��� c�. �. c� .� �� i
�a� a 3 �� �--�� .
�Subdivision�Name Lot No: Sec. or Block Na
-� ,_. �._ ._. .
.. .�,.___�_.�._�..�.._ _ . . ,.._ . , , . ,
, _.. . _
� Lot Size �•��''�'''' lyHousey ��� �"Mobile�Home - Business Industry .�;;,�
-... . ....�_
�i ,, , - .
No. Bedrooms�.No. Baths � No, in Family�_ Public Assembly Other
: Garbage DisposaL YES p NO-d ,; Specifications for System:
" �:
Auto Dish Washer YES � NO ❑ ' �: ,/p o o�,o�: ��;��, � �-$�
� Auto.Wash Ma;hine YES d NO p� ` ► � �� ' .
� �� x � �.� . ��, _
TYPe Water SuPP�Y ��-�" � ---� �O � 5�:�, .
'This permit Void if sewage system described below is not installed within 6 yearsfrom date of issue. �.
This permit is subject to.revocatio i�ite plans o the intended us , hange. � -
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Im rovements ermit,b `�� C3`����� '
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•Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M.,
1:00-1:30 P.M.'or 4:30-5:00.P.M,on day of completion.Telephone Number.704-634=5985. �
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Final Installation Diagram: System Installed by`_
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Certific�t�of Completion Date
�'-' 'The signing of this certificate shall indicate that the system described above has:been' installed in compliance with;
: 'the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time. �