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461 Juney Beauchamp Rd.-.aM 4e':. r�.:a'�dir tiv'�>' ,. r �r.;:.w ..L.,,,;,�" ,5_::'t..,. ... ..... ., .. .. vi ... ., _ ,,...._._.,.. __. .. _. ..__ •���py�.���.� 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 f/�� r%' 'ri7, c3,r > �� ✓ - Date Location .•�5 y }i %,r`"rr'S " . ✓� �- , .-� �� /– ✓r".` Subdivision Name ` Lot No. Sec. or Block No. Lot Size ��r House Mobile Home _ Business __ Speculation No. Bedrooms No. Baths :2? No. in Family ? Garbage Disposal YES ❑ NO [�� � •,Specifications for System: Auto Dish Washer YES NO ❑ / `( j ' Auto Wash Machine YES NO ❑ f -, Type Water Supply c ___ 'This permit Void if sewage system described below is not installed within 36 months from date of issue 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. Telephofie Number: 704-634-5985. Final Installation Diagram: / System Install d by,�s—} Certificate of Completion !��''`f _ Date��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 above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. MAY d � APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 ` Mocksville, N.C. 27028 C� CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 7 1. Permit Re uested By 14,,1115.41n Business Phone 2. Address '7617E 3. Property Owner if Different than Above 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: Houseome Business Industry Other b) Number of people 12 6. a) If house or mobile home,, state size of/home and number of rooms. House Dimensions—D& 'X (�Lo 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 ^- urinals lavatory showers dishwasher sinks j garbage disposal washing machine 8. a) Type water supply: Public �J Private Community b) Has the water supply system been approved? Yes No 9. a) Property Dimensions r -4«e 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 correct to the best of my knowledge.. Date Owner Signatures OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: FRof� ocksr��l�� Comae 00WV //%cagy /6-F LA5T, C©,%? E' To !� � l3 ) , C©1��e D 7, VIY 40 06DuT10'1/e T X y llk,l fMWo FXV IAI -4T TWA FAX";'� 7-0 IN 7716-b DCHD (6-82) Th�E T�/A/LedL TI -1147 14/*s /� i L Y Y DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name Date Address Lot Size FAr:Tr1RR AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/ Landscape Position 4) 5) 6) 8) 9) S S S PS S PS U U U U ?) Soil Texture (12-36 in.) Sandy, Loamy, Clayey, (note 2:1 Clay) S /� <: S PS S PS S PS U U 3) Soil Structure (12-36 in.) Clayey Soils S S � S PS S PS U U U Soil Depth (inches) dpi� S PS S PS U U U Soil Drainage: Internal S ��, S (�51 S PS S PS �—� ''fib--�� U U External S S PS S PS `'tom U U Restrictive Horizons Available Space Pg S S S PS S PS U U U U Other (Specify) S PS UU S PS U S PS U S PS U Site Classification U—UNSUITABLE Recommendations /Comments: S—SUITABLE�PS—Provisionally Suitable Described byTitle SITE DIAGRAM S DCHD (6-82)