P3750 John NickelsIL DAVIE COUNTY HEALTH DEPARTMENT
s IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION j
`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 %�'. ; _� Date //�j r' ^,Y a7 r-
0
v
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home — Business -- Speculation
No. Bedrooms No. Baths 4/ No. in Family
Garbage Disposal YES p NO [:] Specifications for System:
Auto Dish Washer YES [ NO p
Auto Wash Machine YES] NO �'
Type Water Supply /�'�1y - ;TXZ
`This permit Void if sewage system described below is not installed within 36 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.
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Final Installation Diagram:
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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size
GA(:T(1RC AREA 1 AREA 9 ARFA .'q APPA A
5
6)
8)
1) 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
�) 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
Restrictive Horizons
Available Space S S. S S
PS PS PS PS
U U U U
Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE
Recommendations/ Comments:
Described by
SITE DIAGRAM
DCHD (6-82)
S -SUITABLE PS—Provisionally Suitable
Title
Date
U—UNSUITABLE
Recommendations/ Comments:
Described by
SITE DIAGRAM
DCHD (6-82)
S -SUITABLE PS—Provisionally Suitable
Title
Date
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size
FAr.TORR AREA 1 AREA 9 ARFA A APPA d
1) 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
3) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
PS
PS
PS
PS
U
U
U
U
1) Soil Depth (inches)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
i) 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
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)
STATEMENT
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
210 HOSPITAL STREET
P. 0. BOX 665
MOCKSVILLE, NORTH CAROLINA 27028
(704) 634-5985
DETACH AND MAIL WITH YOUR CHECK. YOUR CANCELLED CHECK IS YOUR RECEIPT.
J BALANCE DUE -