202 Jerusalem Ave DAVIE COUNTY HEALTH DEPARTMENT
i 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/r% �. %l// S- < �>> ;�r Dated i '%
a t3 r
Location �.l �'l<�r- i��" ,i�/;. r /•;. , rt` v ,:.iti/c >.�t /%,.='�
Subdivision Name Lot No. Sec. or Block No.
Lot Sizer ' House Mobile Home L'"�Business Speculation
No. Bedrooms No. Baths �� No. in Family _
Garbage Disposal YES p NO ❑.- Specifications for System:
Auto Dish Washer YES NO ❑
Auto Wash Machine YES 4 NO
l�/
Type Water Supply < /
This permit Void if sewage system described below is not installed within 36 months from date of issue.
I� ;1
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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
Certificate of Completion Date J
P F.
'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.
y
e DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS
U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS ( PS PS
l7 U U
3) Soil Structure (12-36 in.) S S
Clayey Soils PS PS
U U U U
4) Soil Depth (inches) S^ � S S ;
®I �F' PS PS
U U U U
5) Soil Drainage: Internal � S S
l.P PS PS
U U U U_
External SS S
�'PS� PS PS
U �� U U
6) Restrictive Horizons
7) Available Space S� S S
1 �w PS PS
U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification , . JW�
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by �G� Title
SITE DIAGRAM
DCHD(8-82)