576 Juney Beauchamp Rd (2) DAVIE COUNTY HEALTH DEPARTMENT
IMMOVEMENTS PERMIT AND :CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
Name cas' y ;. /r ,7'� roll".r �. '� Date f ,� 5 8 0 o
Location „�!�' - . rtey i —s-
y
Subdivision Name Lot No. Sec. or Block No.
Lot Size, i House Mobile Home _ Business __ Speculation
No. Bedrooms No. Baths No. in Family _
Garbage Disposal. YES ❑ NO Specifications for System:
Auto Dish Washer YES NO ❑
Auto Wash Machine YES NO ❑ led
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.
F. 1
Improvements permit by
*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: / d System Installed by
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Certificate of Completion G" 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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name ��lf-� Date
Address Lot Size ! TSL
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position ® �> S S
PS S PS
U U 6V
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay) A & S S
U U
3) Soil Structure (12-36 in.) 8r-- S
Clayey Soils S S
4) Soil Depth (inches) S
PS df S S
U
5) Soil Drainage: Internal SS
S
U
External
� (PSS S
6) Restrictive Horizons
7) Available Space S
PS PS S
U U
8) Other (Specify) S S S
PS PS PS S
U U U .
9) Site Classification 1 00 - V.�• v S�
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: =� �o �✓
Described by Title ��r Date
SITE DIAGRAM
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UCHU Its 82)
AF- PLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health DepartmentC;��
Environmental Health Section
\ v R 0. Box 665
Mocksville, N.C. 27028
5 `•� �_�CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
/ 7_Z1;-7Z_
7` Home Phone
1. Permit Requested y s ;�:l 1 Gi—TL c. r, Business Phone
✓ ;�
2. Address
3. Property Owner if Different than Abovec� ��
Address -_
4. Permit To: a) Install Alter Repair.
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No,
5. System used to serve what type facility: House Mobile Home Business
Industry Other
b) Number of people
6. a7 If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms J Bath Rgoms ?� '" � Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste.daily (24 hours)_
7. Number and type of water-using fixtures:
commodes - urinals garbage disposal
lavatory showers �— washing machine
dishwasher _,� sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions a S i V.
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions,of the facility this sewage system is intended to serve?
What type?
This is to certify that the information is co rec to'liebesity knowledge.
1
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to prop rty:
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