P3123 James BulloboughDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`Note: Issued ir Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name Date <�
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size t r� ` House "`s Mobile Home — Business Speculation
No. Bedrooms`No. Baths `" No. in Family --�
Garbage Disposal YES ❑ NO ❑ Specifications for System:/0'" , f'.. 'r4
Auto Dish Washer YES ❑ NO ❑
Auto Wash Mac ine YES ❑ NO ❑
Type Water Su ply :'�• tr -- '� 4: 1 J... c.
*This permit Vglid 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 Wit,ll`°d
Certificate of Completion
t
*The signing f this certificate shall indicate that the system described above r
the standards set forth in the above regulation, but shall in NO way be taken as a
satisfactorily or any given period of time.
1 If Z
Date
,been\installed in compliance with
arantee that the system will function
1
Name
Address —
U CL6QavG
GA r:Tr) R C
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
. P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
H Date
Lot Size Z c(l
APPA I AREA 9 ARFA I ARFA d
2
) Topography/ Landscape Position S S S
PS PS PS PS
U U U U
) Soil Texture (12-3 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) ® PS PS PS
U U U U
3) Soil Structure (12»36 in.) S S S
Clayey Soils Pr PS PS PS
U U U U
#) Soil Depth (inche) S S S
PS PS PS PS
U U U U
5) Soil Drainage: Int rnal (!5Z)S S S
PS PS PS PS
U U U U
Ex ernal S S S S
11�s PS PS PS
U U U U
�) Restrictive Horizons
') Available Space S- S S
S PS PS PS
U U U U
8) Other (Specify) � pS PS PS
U U U U
►) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
3ecommendations/omments:
)escribed by Title Date
SITE DIAGRAM
DCHD (6-82)
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
DATE Z�- 2-
F << oTSSv
DETACH AND MAIL WITH YOUR CHECK. YOUR CANCELLED CHECK IS YOUR RECEIPT.