2537 Corntzer Road Lot 21. Permit F
2. Address
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT i2
Davie County Health Department f'}`
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
.L_Home Phone
By C� r S �, �' ti Business Phone 7e0'_5-- D /S
3. Property Owner if Different than Above
Address 12± --1' 1qjve. w c c�
4. Permit To: a) Install ✓Alter Repair
b) Privy Conventional zZ Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House ✓Mobile Home Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 3*rX a-9/
Bed Rooms__ Bath Rooms _r 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 urinals garbage disposal
lavatory showers washing machine
dishwasher ( sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 161) X �LOb
b) Land area designated to building site -+y ii r t 161—
c) Sewage Disposal Contractor 'nH-S
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? A,14
What type?
This is to certify that the information is correct to the best of my knowledge.
-_5 _Aj
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
_—tt,t.e_
DCHD (6-82)
0
I
DAVIE COUNTY HEALTH DEPARTMENT LAI
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name 45 Date
Address Lot Size
FAr.TOPR ARFA 1 ARFA 7 ARFA R ARFA A
Topography/ Landscape Position
S
S
S
S
®
PS
PS
PS
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
<::�>
PS
PS
PS
U
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
rqm:�
PS
PS
PS
U
U
U
U
1) Soil Depth (inches)
S
S
S
S
PS
PS
PS
U
U
U
U
i) Soil Drainage: Internal
S
S
S
A;�'
PS
PS
PS
U
U
U
U
External
S
S
S
S
C17>
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
Available Space
S
S
S
S
�
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
!) Site Classification
U—UNSUITABLE
Recommendations/ Comments:
S—SUITABLE ",P,.S—Provisionally Suitable
Described by O •`n^�N- iTitle61�rt,_� Date
SITE DIAGRAM
i�
I
�P� 3 X
DCHD (6-82)