112 Juney Beauchamp Rd (2)• .:v...-�..v. .."v'.�-.�as�v n.x.`--x-........-� :.._..:r:- ...._ a a J - ... �.a... - .. - ..
4 1
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 2n G; Date , ! da "
Location 9'
Subdivision Namee-� Lot No. Sec. or Block No.
Lot Size�CTc House Mobile Home _ Business Speculation
No. Bedrooms _ — No. Baths_ No. in Family Al
Garbage Disposal YES [j NO El'
Sped fics ions for ystem:
Auto Dish Washer YES NO p � /
.0
Auto Wash Machine YES [j NO •p
Type Water Supply ��� --- ,��Q ��✓t�� ,. _
*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. Telephone Number: 704-634-59885.
Final Installation Diagram: System Installed by
l
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.
A$
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Henry Watson Dulin Date
Address Rt. 4, Box 54 Lot Size 1 acre
Advance, NC 27006
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
PS PS
U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) ::::�S PS PS
U U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils (:93 PS PS
U U U
4) Soil Depth (inches) S S
S, PS PS
U U
5) Soil Drainage: Internal S S
PS PS
U U
External SS S
( SO"' PS PS PS
U U U
6) Restrictive Horizons
7) Available SpaceS S S
PS 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 41S I
U—UNSUITABLE S—SUITABLE CPS—Provisionally Suitable
Recommendations/Comments:
Described by Title Sanitarian Date /
SITE DIAGRAM
DCHD(8-82)
RECEIVED MAY 3 0
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
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 Re uested By 907 10 4 hl Business Phone
2. Address - s h(-, J-76
3. Property Owner if Different than Above +//
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional_-�70ther Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Homed Business
IndustryOther
b) Number of people 2
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions '70
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 garbage disposal
lavatory. 'Z showers 1 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 f _
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 Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
S176 a-
d a'Zc q —
DCHD(6-82)