170 Wall StDAVIE 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,7Disposal Rules (10 NCAC 10A .1934-.1968) / Permit Number
Name Date `"�//`u 3570
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size !''` T dZZ!!�,' House Mobile Home _ Business _— Speculation
No. Bedrooms No. Baths Z No. in Family _
Garbage Disposal YES F] NO [-r''
Specifications for System:
Auto Dish Washer YES T NO p
Auto Wash Machine YES NO E]
Type Water Supply
*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.
Final Installation Diagram:
System Installed by
Certificate of Completion 'Z r„�Date U -'/0
'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
ate Address Lot Size
FAC T(1RC
APPA 1 APPA 9 AREA 3 ARFA d
Topography/ Landscape Position
S
S
S
PS
PS
PS
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)PS
PS
PS
�4
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
PS
PS
PS
U
U
U
�) Soil Depth (inches)
S
S
S
PS
PS
PS
U
U
U
Soil Drainage: Internal
S
S
S
S
PS
PS
PS
U
U
U
External
S
S
S
S
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
') Available Space
S
S.
S
S
PS
PS
PS
U
U
U
1) Other (Specify)
pS
S
PS
S
PS
S
PS
U
U
U
1) Site Classification
U—UNSUITABLE
Recommendations/Comments:
Described by _
SITE DIAGRAM
f
DCHD (6-82)
S—SUITABLE PS—Provisionally Suitable
Title