348 Beauchamp Rd (2) DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
Name it <%, / !J"/ i.r'r;"ryb*,"):%,!��4 ` Date .1- 4 -;✓�} N2 5823
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size is/C House Mobile Home �/'� Business Speculation
No. Bedrooms -- No. Baths No. in Family _
Garbage Disposal YES ❑ NO 2- Specifications for Sy tem:
Auto Dish Washer YES NO ❑ � � �� �
Auto Wash Machine YES [tj NO
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.
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Improvements permit by ---&/ L/
*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 bye-� �.�-� � -S
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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 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
Environmental Health Section
P. 0. Sox 665 JAN 6
Mockaville, NC 27028 REEEtVE�
1 . Application/Permit Requested By 1--nL rC\OWrw-
Maliling Address
Home Phone C SZ ` 14 16) Business Phone
2. Name on Permit if Different than Above
:3. Prloperty Owner if Different than Above L-lober+
4. Application/Permit For: LC) General Evaluation Q' b/Tank Installation
5. System to Serve: House �obile Home 0 Business
Industryu Other Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People Dwelling Dimensions
No. of Bedrooms Basement/Plumbing
Na. of Bathrooms Basement/No Plumbing
.Washing MachineU 'Dishwasher (3 Garbage Dispusai
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
8. Type of water supply : Public- 0 Private () Community
9. Property Dimensions
10. Sewage Disposal Contractor A-0 r,\
e
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? Q Yes `,Q/ No -
r
Ifl yes, what type?
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*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 tree
best of my knowledge, and I understand I am responsible for all
,charges incurred from this application.
I - % - go �A QLJ� C'nA-T-Q 'k-
Date Signature
Directions to Property :
Come A-r3 3e o cher
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DCHD (110-A9)
' IF DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section,
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION 7
Name ��7` Date
Address Lot Size `re
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position ® S
PS S S PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S -
Loamy, Clayey, (note 2:1 Clay) PS
U U U
3) Soil Structure (12-36 in.)
Clayey Soils tp
U tT U U
4) Soil Depth (inches) � _---7t>
U
U U
5) Soil Drainage: Internal S S
..• U U
External � S _
P PS
6) Restrictive Horizons
7) Available Space
PS PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification j t C L
U—UNSUITABLE S—SUITABLE Provisionally Suitable
Recommendations/Comments:
Described by � Title >"�� - Date
SITE DIAGRAM
DCHD(6-92)