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, APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
` Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 7LZ`� ��q�- ����
1. Permit Requested By ���---� � ��'�< �- Business Phone 9�`I��R�� �b'3y��
2. Address �'� Ln—�cy� 4� - f� �l c� �C c.s '` `.`� C��' . Zn t��'1-.�
3. Property Owner if Different than Above
Address
4. Permit To: a) Install � Alter Repair .
b) Privy Conventional ✓ Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
Industry Other
b) Number of people �
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 7S � ?� 3b�
Bed Rooms�—Bath Rooms �� 'L Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes '3 urinals garbage disposal �
lavatory � showers � washing machine 1
dishwasher sinks S-
8. a) Type water supply: Public Private ✓ Community � G--���e.�-� h�-'e- ''-��-�-
b) Has the water supply system been approved? Yes ✓ No
9. a) Property Dimensions � �/z �s c-�� �oo�.�.
b) Land area designated to building site `���` ,� `35 �
c) Sewage Disposal Contractor '\o��•.� �', �,,nc� � `70�d - 4 t��- �h�J
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? nb
What type?
This is to certify that the information is correct to the best of my knowledge.
/D- I`l�- ��r �.�,�� � -�-� :��
Date Owner Signature �
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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•� pAVIE COUNTY HEALTH DEPARTMENT
�
� Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOiL/SITE EVALUATION
Name ���� � a �� �S Date
Address Lot Size �� �
FACTOR$ AREA AREA�2.J AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS � PS PS
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 �p�' P PS PS
� U U U
4) Soil Depth (inches) ` ,� S S
PS <�S PS PS
U U U U
5) Soil Drainage: Internai S S
pS PS PS PS
� U U
External � S S
PS PS PS
� � U U U
6) Restrictive Horizons `��
7) Availabie Space S S S
PS PS PS PS
U � U U U
8) Other (Specify) S S S S
pg PS PS
U U
9) Site Classification �
U—UNSUITABLE S—SUIT —Provisionally Suitable
Recommendations/Comments:
Described by� Title � +�N-- Date� a ��
SITE DIAGRAM
� i
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� �
DCHD�6-82)