566 Beauchamp Rd —_ - .: - --"�1'-: �•'F'- - _-__. -......wvvy„•w .T+s•s... -.a....�1 i+ei W:3vr. •e�._....-.�..r... .-
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r: DAVIE iCOUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE' OF COMPLETION
'.NOTE: Issued in Compliance with G.S. of North,Carolina Chapter 130 Article 13c .
I
Sewage Treatment and Disposal�.Rules (10 NCAC 10A .1934-.1968) Permit Number '
Name i � -Date � � � 4726
Location INA 14
Subdivision Name II Lot No. Sec. or Block No.
Lot Size _ HouseI U' it Mobile Home Business —_ Speculation
No. Bedrooms 'No.-.Baths �I No.yin Family l _
Garbage Disposal YES. p NdI I I.
�i l Specifications for ,_System:
Auto Dish Washer YES ��, NO;IX i ��5�h •;,,
Auto Wash Machine YES NOi1 p
Type Water Supply VI)•���.' L — it
11
*This.permit Void if sewage system dlescribed below is not installed witliin 36 months from date of issue.
• . X11 �.�.. . �� . • • .
r 1 v
Improvements permitby —\ --- .. .
�• II
I
*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 : 7047-634-5985.
1
Final Installation Diagram: �I. • ' " System Installed by
tj
. i
Certificate of Completion Date
P P '
'The signing of this certificate shall indicate that the system described, above has been installed in compliance with
the standards set forth in the aboveregulation..
, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period ofjtimei II
i�
` APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT 0
Davie County Health Department
Environmental Health Section
5R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
�i�
Home RhSg I gZ9 6
1. Permit Requested By 1 �CBusinbons
2. Address r'
3. Property Owner if Different than Above
Address
4. Permit To: a) InstallsCAlter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House4,*Mobile Home Business
Industry Other
b) Number of people j
6. a) If house or mobile home, state size of home and number of rooms.
-House Dimensions 3 S X 'S d
Bed Rooms—Bath Rooms Den w/Close
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 Nom
9. a) Property Dimensions ,3 o[ ra.�
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?. N(4
What type?
This is to certify that the information is correct to the best of my knowledge.
4 - 3 - 2 - , P
i n If)/-) j
Date 020ner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
( flee i–-9 1r0 o.�, c q 46 Q � �M�
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LAC LA_ g�� 0 UA r C
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DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name �� ` Date
Address Lot Size
FACTORS ARIZA ARE 2 AREA 3 AREA 4
1) Topography/Landscape Position --6 9) S S
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U
3) Soil Structure (12-36 in.) S S
Clayey Soils PS PS
U U U U
4) Soil Depth (inches) (:Is> S S
PS 4s) PS PS
U U U U
5) Soil Drainage: Internal S S S
: (�A> PS PS
U U U U
External (jp A S S
PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S
P PS PS PS
U U U
8) Other (Specify) S S S S
PS PS PS
U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS rovisionaliy Suitable
Recommendations/Comments:
Described by �-^ J;a� Title Date
SITE DIAGRAM
DCHD(6-82)