107 White Oak LnDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:�ls�sued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
•` Sewage Treatment and Disposal Rules S10 NCAC 10A .1934-.1968)
Name
r � '
Permit Number
Subdivision Name Lot No. Sec. or Block No.
Lot Size`
���_ House Mobile Home _ r Business Speculation
No. Bedrooms -? No. Baths No. in Family 7 --
Garbage Disposal YES ❑ NO ❑,,.
Specifications for System:
Auto Dish Washer YES T NO ❑ -
Auto Wash Machine YES NO -❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
1
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 -A > p \c
i
t
Certificate of Completion Date r
*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
r. satisfactorily for any given period of time.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
j Mocksville, N.C. 27028
SOIL/SITE EVALUATION
NameADate
Address Lot Size—
cArrTnRc AREA 1 AREA 9 AREA 3 AREA d
2)
3)
5
8)
9) Site Classification
Topography/ Landscape Position S S S S
PS PS
U '[T U U
Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) (195PS PS
U U U
Soil Structure (12-36 in.) S S S
Clayey Soils PS PS
U U
4) Soil Depth (inches) S S S S
p � PS PS
U U
) Soil Drainage: Internal S S S S
PS PS
U U
External SS S
S (PS) PS PS
U U
�) Restrictive Horizons C>ZU
Available Space S S S S
S PS PS
U U U U
Other (Specify) S S S S
PS PS PS PS
U U U U
U-1
Recommendations/ Comments:
S—SUITABLE PS—Provisionally Suitable
Described by — Title Dat l
SITE DIAGRAM
)�Vl�& 3111ve
DCHD (6-82)
U-1
Recommendations/ Comments:
S—SUITABLE PS—Provisionally Suitable
Described by — Title Dat l
SITE DIAGRAM
)�Vl�& 3111ve
DCHD (6-82)