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574 Juney Beauchamp Rd _ SCO DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article II of G.S.Chapter 130a Sanitary Sewage Systems w >' _3'j14 "i f Permit Number Name y A/1' , ; 1) r r t? �- Date ND 5862 V Locatio / `.''- f r ,e,,� J1 r• , r� etF` z" ,✓' — Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _ Business -- Speculation No. Bedrooms _ No. Baths —s — No. in Family -� — Garbage Disposal YES ❑ NO ,lam Specifications for System: Auto Dish Washer YES d NO -[:) Auto Wash Machine YES,©` NO ❑ � �v✓ J� f ' Type Water Supply *This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change. Improvements permit by —4k ZZ T—. *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 day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by f I l Z 1 Certificate 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 1n N,O way be taken as a guarantee that the system will function satisfactorily for any given period of time. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department 1 1990 Environmental Health Section 0��8 P. 0. Box 665 Mockaville, NC 27028 R P60Y 1 . A lication/Permit Re uested B A � PP 4 Y Mailing Address R�• �1 g�X 383 �O,v� S�. �•5• �•C• g�7lo-7 Home Phonl'q -?(Pq- Business Phon qI� -2Z,el— �0 2. Name on Permit if Different than Above ";'0'rnF- 3. Property Owner if Different than Above &rnf- 4. Application/Permit For: lC) General Evaluation PIS/Tank Installation S. System to Serve: House u Mobile Home Q Business Industry u Other 0 Unknown 6. If house, mobile home: Subdivision IVO Sec. � Lots No. of People a Dwel l i n Dimensions a 7�1 S 7LNo. of Bedrooms VBasement/Plumbing of Bathrooms ` Basement/No Plumbing Washing Machine dishwasher 0 Garbage D:rsposai 7. If business, industry, other: Specify type No. of People Served No. of Sinks No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers S. Type of water supply: C Public 0 Private 0 Community 9 . Property Dimensions J AC' . `5, 10 . Sewage Disposal Contractor, 11 . Do you anticipate addi ions/expansions of the facility this system is intended to serve? es 0 No If yes, what type? �DSTl9/2S ,B��1, eoopn *NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this apple anon. Q - 13 - 90 Date Signature Directions to Property : I� / —' ,Sid o -A0 y y Aa I ,a�f al DCHD (10-89) DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION SITE EVALUATION CONSENT FORM 1. Complete the form below and return to the Davie County Health Department. 2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin." NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO BEGIN THE REQUESTED EVALUATION. DETACH HERE AND RETURN TO: Davie County Health Department, Environmental Health Section, P. O. Box 665, Mocksville, N.C. 27028 Davie County Health Department Environmental Health Section Site Evaluation Consent Form LOCATION OF PROPERTY: DATE RECEIVED -f'- (office VAJ/6 &hd,.)jA1rW If� /&3 use only) yes no 1. I am the owner of the above described property. yes no 2. 1 am not the owner of the above described property, however, I certify that I have consent from �� zs�,mhp— - , owner to obtain a owner's name site evaluation by the Davie County Health Department for the purpose of determining the suitability for a ground absorption sewage treatment and disposal system. yes no 3. 1 hereby give consent to the authorized representative of the Davie County Health Department to enter upon the above described property and conduct all testing procedures as necessary to determine its suitability for a ground absorption sewage treatment and disposal system. a_13� 9 DATE V SIGNATURE 4. 1 hereby authorize the Davie County Health Department to release site evaluation resul from the above described property to the following: wner only Owners designated representative _Anyone requesting results — Only those listed below DATE SIGNATURE DCHD(11/84) }' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name 'r Date Address Lot Size—.� FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S SS S PS (�p g�? U 2) Soil Texture (12-36 in.) Sandy, S S Loamy, Clayey, (note 2:1 Clay) S rS U 3) Soil Structure (12-36 in.) S Clayey Soils S S ( � 4) Soil Depth (inches) S S 5) Soil Drainage: Internal S S P External S PS 6) Restrictive Horizons I 7) Available Space S S p PS PS PS U U 8) Other (Specify) S S S S PS PS U U U 9) Site Classification U—UNSUITABLE S—SUITABLE PS_—)?rovisionally Suitable Recommendations/Comments: 6 ? Described by �/� Title '--La Date SITE DIAGRAM DCHD(6-82)