1131 Godbey Rd . .DAVIE COUNTY HEALTI-Iii DEPARTMENT
! IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'h`%►e: Issued in Compliance with G.S. of North Carolina Chapterill 30—Article 1.3c.
Permit Number
NameDate
,
Location ,°'..i✓ �'_ L pro ! �"c`j c,;,� r i" 1'ii/!7?! `lF/{ Jr%d' / / /
:* :: tl !" 6 r' r�,'f "t' %� .✓,"br '7 d ! °' r'r fff /' r/,/?
Subdivision Name �{ Lot No. Sec. or Block No.
Lot,.Size, _ House Mobile. Home ' Business —_ Speculation
No..Bedrooms No. Baths _ No. in Family ( _
Garbage Disposal` YES E] NO [211` Specifications for System:
Auto Dish Washer. YES Efl NO F
Auto Wash Machine YES 0 NO
Type Water Supply
This permit Void if sewage system described below is not installed within 36 months from date of issue.
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it
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 1:0071:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by
,I
i ,�
. 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. il'
I
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 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 S
y PS PS
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) �� (:: �E � U PS
3) Soil Structure (12-36 in.) S S S S
Clayey Soils cl% PS PS
U U U U
4) Soil Depth (inches) SS S S
PS PS
U U U
5) Soil Drainage: Internal ,�S - S S S
( � PS t
U `-�" U U U
External S S S S
PS PS PS PS
U U U U
6) Restrictive Horizonsi
7) Available Space S. S S
p/ PS PS
P U P U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site-Classification
�7 J
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title —,?Fl�i� Date
SITE DIAGRAM
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DCHD(6-62) r,