P3644 Mickey Shore-.y
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 f � ��s �' Date �;`�,! ` �'��i' 'i2 3644
"
Location
r
Subdivision Name Lot No. Sec. or Block No.
Lot Size �%� House Mobile Homey Business Speculation
No. Bedrooms=�' No. Baths �� No. in Family_
Garbage Disposal YES ❑ NO ❑
Auto Dish Washer YES NO E]Specifications for System; ;•
Auto Wash Machine YES NO ❑
Type Water Supply
*This permit Void if sewage system described below is not installed wi�thip A6 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: 704-634-5985.
Final Installation Diagram:
� l
System Installed by
--
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.
STATEMENT
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
210 HOSPITAL STREET
P. 0. BOX 665
MOCKSVILLE, NORTH CAROLINA 27028
(704) 634-5985
DATE
DETACH AND MAIL WITH YOUR CHECK. YOUR CANCELLED CHECK IS YOUR RECEIPT.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size
FAr Tr1RC AREA 1 ARFA 9 ARFA R ARFA A
Topography/ Landscape Position
S
S
S
S
PS
PS
PS
PS
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
PS
U
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
PS
PS
PS
PS
U
U
U
U
G) Soil Depth (inches)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
�) Soil Drainage: Internal
S
S
S
S
PS
PS
PS
PS
U
U
U
U
External
S
S
S
S
PS
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
4
Available Space
S
S.
S
S
PS
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
DCHD (6-82)