178 Beauchamp Rd }�.
DAVIE .COUNTY .HEALTH DEPARTMENT , - -
. IMPROVEMENTS PERMIT AND CERTIFICATE OF CR.MPLETION,'(
NOTE':tt-'Jssued in Compliance with G.S. of North Carolina ,.Chapter 130 Article-13c.
Sewage Treatment and Disposal Rules 0 !NCAC_1-0A .1934-.1968) Permit Number
Name—� ,-,.�- i%, Date � /�t� 4243
Location ��/ %r�•'�,.a_ ' ."i'j /.fir u'�{`, ` ,% •f ._ �f�y mix`>_ -,a.
Subdivision Name i,�t Lot No. Sec. or Block No.
LotSize:'r�,rF, �'
—� House; ,M I+bilb Home._ Business Speculation
No. Bedrooms No. Baths ® f
— No ,iin(Family.
Garbage Disposal YES NO
Specifications for. System:
Auto Dish Washer YES 7 N0
Auto.Wash Machine YES UJ NO
1,r_
y
Type Water Supply / ✓,�1'6' �i _ �C, X `J �:
'.."This permit Void if sewage system described belowi islnot installed within 36 months from date of issue.
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. : - . •; , 1, !� .�...�._. .
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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: 704763,4=5985
.- III i; ..' •
Final Installation Diagram: System'lnstalled by
A
ol .;oo
= ,t
icas2f Com letion 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 tfe'system will function
satisfactorily for any given period of time.
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMITF,
Davie County Health Department .'p
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
_ Home Phone
1. Permit Requested By /'�4/ �'?12Nr�'G Business Phone
2.-Address Nr °d A60Y 291 A0(117'wC,6: XIC . 2 ?rid e
3. Property Owner if Different than Above
Address IY7-1 po,194,/.�1✓C 1 xfG 2 9Gt4+�
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
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 2.9-410 s�d7,
Bed Rooms Bath Rooms Z 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 41f Community
b) Has the water supply system been approved? Yes No 11�1
9. a) Property Dimensions 2 eO "� X sr/s 01:7X"
b) Land area designated to building siteR13�
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? Ale
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
C/f QS.s lel?'06'ir 4v r er.✓ / r" le'05 7'G✓rf� 6f�r.��'� ,�sr.�Es'
DCHD(6-82) �
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Timothy W. Cranf ill Date
Address Lot Size C24-4a`
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS
U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) � PS PS
U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils �Ip PS PS
U U U U
4) Soil Depth (inches) S S S
PS PS
U U
5) Soil Drainage: Internal S S S
PS PS PS
U U
External S S
PS PS PS
U U
6) Restrictive Horizons
7) Available Space S S S
S S PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U� U U U
9) Site Classification ,, ,
U—UNSUITABLE S—SUITABLE S=Provisionally Suitable
Recommendations/Comments:
Described by / Title !%f��' Date
SITE DIAGRAM
F
1
DCHD(6-82) - -