119 Jolley Rd DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND Ii CERTIFICATE OF COMPLETION -=---
`NOTE: Issued in Compliance with G'S. of North Carolinai!Chapter_130 Article 13c
- ` Sewage Treatment and Disposal Rules (10 NCAC '10A .1934-.1968); Permit Nlumber
Name n NC ;Date - ? p�q{gp� 5137
Location .h e `��> 'sus,v. •� .� �,; �, K 1.
Xa i l i � ±l0 's`c•..� '�"^wr�`E.�-a''�*a. _J �I.`?-H,`�c .x.. `'��"`° \�:i..si}l. C�::'�5�.�.- ' _.J�'w:,. �s.1�, `f �':
Subdivision Name J,Lot No. Sec. or Block No.
Lot Size House '�. Mobile Home Business - Speculation
No. Bedrooms No. Baths - No. in Family
Garbage.Disposal YES 0 No , i
Specifications for System:
Auto Dish Washer. YES '❑ NO -
Auto Wash Machine YES [ NO '0
Type Water Supply . 1"_s sz.a _. lr/GS lJ X �S(\
'This permit Void if sewage system described below is not;installed within 36 months from date of issue.
if
- .. .. j 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
it
Certificate of Com letion• G�%�1 Date
. . N -
*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.thafthe system will function''
satisfactorily for any given period of time.
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION E�
Name Date
Address S Q�'�' Lot Size n
FACTORS AR 1 AREA AREA 3 AREA 4
1) Topography/Landscape Position S S
PS ct) PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) P PS PS
U U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils cty PS PS
U U U U
4) Soil Depth (inches) .. S S
p� ( P� PS PS
U U U
5) Soil Drainage: Internal S S
PS PS
lp "G U U
External S S S
S PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S S
PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U
9) Site Classification �V-S)
U—UNSUITA LE S LSE PS Provisionally Suitable
Recommendations/Comments: `'
/ JarQC
Described by `C Title Date `
SITE DIAGRAM
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UCHD(6.82)