1277 Liberty Church Rd DAVIE COUNTY HEALTH DEPARTMENT � iG7
- IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
r"I oTe: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
A Permit Number
Name � f;,?:ji r' <"f ;�;, Date L?
Location
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Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms r No. Baths No. in Family--
Garbage
amily Garbage Disposal YES 0 NO ❑---` Specifications for System:
Auto Dish Washer YES ❑ NO Ey—
Auto
"—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.
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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 Xr"`� �
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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
R 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 <1 S S S
PS PS PS PS
U U U U
2) Soil Texture 12-36 in.) Sandy, S S S S
Loam ayey, note 2:1 Clay) epls� PS PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils <�M> PS PS PS
U U U U
4) Soil Depth (inches) i� S S S S
PS PS PS
U U U U
5) Soil Drainage: Internal S S S S
PS PS PS
U U U U
External S S S
PS PS PS PS .
U U U U
6) Restrictive Horizons
7) Available Space S S- S S
PS PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by �`�` �� Title —,�,�-���� Date
,SITE DIAGRAM
a;
s.
DCHD(6-82) - •'