121 Reece Way DAVIE COUNTY HEALTH DEPARTMENT
' •'" IMPROVEMENTS PERMIT AND .CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
Sanitary Sewage Systems ! , Permit Number
Name : a i/ f�,r �- :- � � �'.' ,Date /'r; .f % 0
6556
LOcatlOn
/��/fiJ"!t'. 7l. / `'jj. f-''��/. � �.!' �' _i_ .. I � C,1.-d.c r�t•�C1/1'r;,1"� �C�.
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Subdivision Name Lot No. Sec. or Block No.
Lot Size House �� Mobile Home __ Business Speculation
No. Bedrooms .No. Baths c2 No. in Family _
Garbage Disposal YES.E3 NO �3' Specifications for System:
Auto Dish Washer YES p NO ❑
Auto Wash Ma.hine YES P 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.
I .
`��
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 704-634-5985.
Final Installation Diagram: System Installed by � �1
l/
N
Certificate of Completion Date ..2 - 'Z_
y �'
*The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the abovejegulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
1� ►� I
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI RECEIVE
Davie County Health Department
�
Environmental Health Section c ..P. O. Box 665' AUG '13 1.991
��' � �. Vis. ... .... . . . . .
P1 Mocksville, NC 27028 -
1. Application/Permit Requested By X-Al n1y /y
Mailing Address 3S2(;2 P� c S:f . ��%�soh S,4/e rn ,/);! C. a
Home Phone ���`��7$5 -oa �� Business Phone S42-lc
2. Name on Permit if Different than Above —/
3. Application/Permit for: ❑ General Evaluation Lel Septic Tank Installation
4. System to Serve: I(House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
❑ Basement/Plumbing
No. of People 2 ❑ Basement/No Plumbing
No. of Bedrooms 3 EWashing Machine
No. of Bathrooms a 4 D/Dishwasher
40 Dwelling Dimensions S" !X 3DB S�� S�' El Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Seared No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: L9 Public ❑ Private ❑ Community
8. Property Dimensions Oxay l&l Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes I/No
If yes, what type?
"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.
Directions to Property: o /Sg. fRoN1 /Jwy -TO l 50 by p75'I" A�a.k ;?n+�JE S -/a
wy
J14ne-7 BeOUC�AI-f/ / n 9a'1t�7e� Qoa
"k- �uS�- 1x+aK4 SJ)Pe�e GGeU<, 4411.14Q� R•chk Gjow
W;11 x l4 �-P '4 -y'^0e) g"'A, �a A
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Sod el-
oh
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OJT
This is to certify that the information provided is correct to the best of my knowledge, and I understand I em res n ible for all charges
incurred from this application.
DATE J SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: 0 1. I OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representative of the DI Co my Health Department to enter upon above described
property located in Davie County and owned by "!5-A;-" 2
to conduct all testing procedures as necessary to determine said site1suitability for a ground absorption sewage treatment
and disposal system.
A /31 /f ( e�'
DATE SIGN URE
DCHD(12-90)
••aria .fain Yfeallf ,qpuy
210 HOSPITAL STREET I P.O.BOX 688
MOCKSVILLE..NIC. 27028 .
PIIomEs(70,M 634.89e5
September:. 14, -1990
t'Roy. Polito
Box` 11
I ") Advai:ee,'.NG 27006 '
`i Re: Site ?Evaluation
t. Lester Beauchamp - 3 Acre Tract
" - Oft 3une Beauchamp Road
Dear,,,Mr. Potts-
AS requested,.'-a representative from this office visited the aforementioned
:r. site on September 11, 1990. The site was found provisionally suitable for the
installation of a ground Absorption, sewage system.
If you have any questions, please feel free to contact this office.
Sincerely,
Robert B. Nall, Jr. , R.S.
Environmental Health Section
RH/wd
Enclosute
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