522 Juney Beauchamp Rd Lot 2 r ..
®" DAVIE COUNTY HEALTH DEPARTMENT
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IMPROVEMENTS PERMIT AND CERTIFICATE OP COMPLETION
'*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewa a Systems Permit Number
Name !>
/ �i Date —L`/- -� N2 7514
Location zf - "' y � �.i�/�t4 �a'a
Subdivision Name —!�-2z �'--� / Lot No. Sec. or Block No.
Lot Size�t '/X/K' House __ Mobile Home _ Business —, Industry
No. Bedrooms No. Baths .2 — No. in Family _ Public Assembly Other
Garbage Disposal YES ❑ NO 2---' Specifications for System:
Auto Dish Washer YES NO E]
Auto Wash Ma^hine YES NO ❑
Type Water Supply _ d
*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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1
S
Imove ents permit b
P P Y
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M.,
1:00-1:30 P.M.or 4:30-5:00 P.M.on day of completion.Telephone Number:704-634-5985.
Final Installation Diagram: System Installed by
F-
.
40
b
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0 Completion ��-� Date
Certificate f C I'
"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 betaken as a guarantee that the system will function
satisfactorily for any given period of time.
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
1
n f � Davie County Health Department
Environmental Health Section S!9
C .�,� �"► P. O. Box 665
�' ►/"� Mocksville, NC 27028
T �t
1. Application/Permit Requested By � � / // E' !P>t�� 7 c4� e
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Mailing Address.411 ���� l�y Home Phone_�9�Y
-/� Business Phone
2. Name on Permit if Different than Above e7 e JZ &V Ifl
3. Application for: ❑General Evaluation j�'Septic Ta k Installation Permit
4. System to Serve: gl House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
❑ Basement/Plumbing
No. of People K Basement/No Plumbing
No. of Bedrooms NT Washing Machine
No. of Bathrooms g Dishwasher
Dwelling Dimensions ❑ Garbage Disposal
6. If business, industry, place of public assembly, 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 Water Usage Figures
7. Type of water supply: Public ❑ Private ❑ Community
8. Property Dimensions 4C^Cs' Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes R'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:
e,iul
This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurred from this application.
5!� 14:�;Z e- 2—�t�DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 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 Davie County Health Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
DCHD(1193)