697 Juney Beauchamp Rd (2) 2
DAVIE COUNTY HEALTH DEPARTMENT
-IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number'
Name T!'� -� Date 3787
Location. —
Subdivision Name Lot No. Sec. or Block No.
Lot Size ;� � _ ,c House Mobile Home Business Speculation
No. Bedrooms No. Baths z No. in Family
Garbage Disposal YES Q NO a Specifications for System:
Auto Dish Washer YES [D. NO Q
Auto Wash Machine YES p NO Q
Type Water Supply � � --- `�: �:,.. r,f' w/.7!••{, ,l ;�i�� , • n.�.�r� b�0.2�
`This permit Void if sewage system described below is not installed within 36 months from date of issue..
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Improvements permit by
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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. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: �Syst`em (Installed by r
2 �
d
Certificate of Completion a,�� Date '"►V � � '
*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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department ( �J tf
Environmental Health Section tl
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HASAEN ISSUED.
Home Ph ne
1. Permit Requested RV Business Phone
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install ✓Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-DivisionSec. Lot No.
5. System used to serve what type facility: House Mome Business
IndustryOther
b) Number of people ��� o
6. a) If house or mobile home, state ohome and number of rooms.
House Dimensions
Bed Rooms - Bath Rooms—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 -3 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-=Z SaC'l to 9.
b) Land area designated to building site—sem^r12a �
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? 4
What type?
This is tce ity that the information is correc t est my k o dge.
-Cfate wner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE A LOCAL LAWS
Allow 5 days for processing
Directions to property:
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Reouest No. : 1239 ',
WASTELOAIi ALLOCATION APPROVAL. FORM
Facility Name : FORSYTH PARTNERS
Tune Of Waste : DOMESTIC
Receiving Stream : UT TO BAILEY CREEK
Stream Class : C
Subbasin : 030705
County : DAVIE
Regional Office : WSRO
Reauestor L.L. ANDERSON
Drainage Area (so mi ) . 14
7010 (cfs) : 0
Winter 7010 (cfs) : 0
3002 (cfs) : 0
------------------------- RECOMMENDED EFFLUENT L.TMITS
5vmn� w.�r
Wasteflow (mgd) : .0036 .0036
5-Dai BOD (mg/1 ) : 30 30
Dissolved Oxygen (mg/1) : 6 6
OH (SU) : 6-8.5 6-8.5
Fecal Coliform (/100ml ) : 1000 1000
TSS (mg/1) 30 30
-------------------------------- -- COMMENTS ------------
-----------------------
A COMBINED FLOW OF .0081 MGD FOR THE PROPOSED PROJECT
WOULD RECEIVE LIMITS OF: 21 NBODY 15 NH3-N FOR SLIMMER
AND WINTER WOULD BE 30 NBOD AS PREVIDLISL.Y ALLOCATED.
i--- ------------------------------- ------------------------------------------------
FACILITY IS PROPOSED ( X) EXISTING ( ) NEW ( )
LIMITS ARE : REVISION ( ) CONFIRMATION ( ) OF THOSE PREVIOUSL.Y ISSUED
--------------------------------------------------------------------------------
RECOMMENDED BY: _. __._. ._.DATE: /0 20 .a __
REVIEWED BY2
SUPERVISORr TECH. SUPPORT -DATE
REGIONAL SUPERVISOR :______.__.__._._..._._...__.__._. ._._.DATE
Approval is ( ) Preliminary ( ) Final
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