1276 Beauchamp Rd , DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
, . , � P.O.Boz 848/210 Hospital Street � ���—b/
Mocksville,NC 27028
(336)75]-87(0
IMPROVEMENT/OPERATION PERMIT
Account #: 990001090 Tax PIN/EH#: 5871-03-7705
Billed To: Danny Whitaker Subdivision Info: �2?(P
Reference Name: William Shayne Beauchamp Location/Address: Beauchamp Rd-27006
Proposed Facility: House Property Size: 2 Acres
ATC N�u�pber: 2868
**NOTE** "1"his 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 1 l 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 r d Vst #People 3 #Bedrooms 3 #Baths 2
Dishwasher: � Garbage Disposal: � Washing Machine: � Basement w/Plumbing: 0 Basement/No Plumbing: �
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: �
Lot Size `��%S Type Water Supply��' Design Wastewater Flow(GPD) ��Do Site: New u Repair❑
�� ,� �
System Specifications: Tank Size���GAL. Pump Tank GAL. Trench Width� Rock Depth �2 Lineaz Ft. �'}�
och�: 2 ��sTe►��no� �0�5 . l�Sj�,�� L�,�,�S �'o.c, �►�.,.�.
Required Site Modifications/Conditions: ��°TQ� (� ����2, �..�r �j' O� �5+�, ������
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 1:30 p.m.on the day of installation. Telephone#is(33G)751-87G0.****
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Environmental Health Specialist's Signa Date: O
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DCHD OS/99(Revised)
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• . � • � DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(33G)751-8760
Account #: 990007090 Tax PIN/EH#: 5871-03-7705
Billed To: Danny Whitaker Subdivision Info:
Reference Name: William Shayne Beauchamp Location/Address: Beauchamp Rd-27006
Proposed Facility: House Property Size: 2 Acres
ATC Number: 2868
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** T'his Authorization for Wastewater System Construction MLTST 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 Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CON RU IS V ID FOR A PERIOD OF FIVE YEARS.
/
Environmental Health Specialist's Signa Date: G Co al
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on Improvement/Operation 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 guarantee that the system will function satisfactorily for any
given period oftime. � �� ,,
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Septic System Installed By: �--1NN T "��
Environmental Health Specialist's Signature: D 1 d t� f�/
DCHD OS/99(Revised)
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' , -03� 7�APPLICATION FOR SITE EVALUATION/IMPROVEMEM PERMIT&ATC D L� � � U l'/ �� �1 '1
��� ����� Davie County Health Department � `
Environmenta/Hea/[fi Section �" 4 2�0�
'' P.O. Box 848/210 Hospital Street
Mocksville, NC 27028 ENVIROt�h1ENTAL HEALTH
(336)751-8760 DAVIE COUNTY
***II�ORTANT*** THIS APPLICATION CANNOT HE PROC�SSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION SUI,LETIN for instruc�ions.
1. Name to be Billed � /'II�Q�l�� Contaet Psraon /t/ �l�Q �
Mailing Addrena !��Q � .(XALIGh�m U ��� 8ome Phone �7�� � -
City/State/ZIP _ (�'fCiIVAJVCP /t�. C, ��QQI� Businea$ Phone 33Co��S7`1'CP�d�
2. Namo on Permit/ATC if Ditferent than AbOve�� // I�/-�I�'� �/�/ai{�l�C f�GGhnMQ
Mailinq Address /!�/'([� PALcCh/aM� �[l . City/State/Zip _ /�pl(�ANL't! ��. 2/d��i
3. Appiication For: 0 Site Evaluation ❑ Improvement Permit/ATC C'l Both
a. sYBt� to ser.,��e: [I House ❑ Mobile Home ❑ Susiness ❑ Industry ❑ Other
5. If Residence: � People ✓ � BedrOOms � t BathroOms �_
B'Diahwasher ❑ Garbage Diaposal �L+l Waahinq Machine ❑ 9asement/Plumbing Cd Basement/No Plumbinq
6. 2f Buainesa/Induatry/Other: Specify type � � People # S1nka
� Co�odea # Showera � Urinala � Nater Coolera
IE FOODSERVICE: # Seats � Estimated Water Usage (gaiiona pe= any)
7. Type of water supply: �"County/City ❑ Well ❑ Community
e. Do you anticipate additions or eapansions of the facility this system is intended to serve? ❑Yes ❑No
If yes,what type?
***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUSTBESUBMI7TED by the client with THIS A.PPLICATIQN.
Property Dimensions: � /aC �' — WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Taz Oftice PIN: # ��7/-/� 3 � �7U� /�i��, /.��� fir� �A�f�mv�c �d�. /K�,� L�igll-+
ylo n
Property Address: Road Name 2 �a�f�mn.r f �r'�( '�(� ��u��n,r.fl�� /KiN �-r-�'t"
City/Zip,�,�(l✓aNC�. �C.. aJ/Xy, a �1 � AS t C
--� _ . .
If in a Subdivision provide information,as follows: 1C� a�v ,l.a�f: ���r�dS �a�
Name: �l,a t vr ��•
Section: Block: Lot: Date Property Flagged: �i.�n.�_ �.,T U�/
This is to certify that the information provided is correct to the 6est of my knowledge. I understand that aay permit(s)
issued hereafter are subject to suspension or revocation,if the site plans or intended ase change,or if the information
submitted in this application is falsi£ed or changed I,also,understand that I am responsible jor all charges incurred from
this application. I,hereby,give consent to the Authorized Representative of the D vie Conn ealth Department
to enter upon above described property located in Davie County and owned by � �
to conduct�11 testing procedures as necessary to determine the site s ' 'lity.
DATE � SIGNATURE �K�
THIS AREA MAY BE USED FOR DRAWING YOUR STTE PLAN(Include all of the following: Eaisting and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Date(s):
1f%5 � Cr f- Q t l�,YS �/a�e �e I����5 � Client Notification Date:
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DAVIE COUNTY HEALTH DEPARTMENT
� � � � � Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001090 Tax PIN/EH#: 5871-03-7705
Billed To: Danny Whitaker Subdivision Info:
Reference Name: William Shayne Beauchamp Location/Address: Beauchamp Rd-270 6
Proposed Facility: House Property Size: 2 Acres Date Evaluated: � S
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition C C
Slo e% �
HORIZON I DEPTH - - D '
Texture rou L C�--
Consistence �
Structure CQ- 5
Mineralo 1; � 1
�
HORIZON II DEPTH - I ' ZJ
Texture rou C G
Consistence �
Structure � �
Mineralo l; � : 1
HORIZON III DEPTH � - �-
Texture rou
Consistence '
Structure 5 c
Mineralo ; � %
HORIZON IV DEPTH F � �(-
Texture rou .
Consistence
Structure
Mineralo
SOIL WETNESS �
RESTRICTIVE HORIZON �
SAPROLITE
CLASSIFICATION �
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: i`� EVALUATION BY: ��� ��N4''►'li!
LONG-TERM ACCEPTANCE RATE: � _� OTHER(S)PRESENT:
REMARKS: �
LEGEND
Landscape Position
R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Tenace FP-Flood plain H-Head slope
Texture
S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt
SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
CONSISTENCE
Moist
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
Wet
NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
Structure �
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineraloev
1:1,2:1,Mixed
Notes '
Horizon depth-In inches
Depth of fill-In inches
Restrictive horizon-Thickness and inches from land surface
Saprolite-S(suitable),U(unsuitable)
Soil wetness-Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less
Classification-S(suitable),PS(provisionally suitable),U(unsuitable)
LTAR-Long-term acceptance rate-gal/day/ft2
DCHD OS/99(Revised)
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