118 Raintree Road Lot 28APPLICATION 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.
1. Permit Requested By -
i
2. Address rZ%10�1
3. Property Owner if Different than Above _
Address
4. Permit To: a) Install�lter
Repair
Home Phone
b) Privy Conventional�Other Type
Groun Absorption
c ?G
Sub -Division Sec. Lot No.
5. System used to serve what type facility: House_===-fVTobile Home Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms__ Bath Rooms 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)
Phone
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 Com unity
b) Has the water supply system been approved? Ye
9. a) Property Dimensions Xt� X206
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
., This is to certify that the information is correct to the best of my knowledge.
X "'V V I
Date Owner' ature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL ATE AND LOCAL LAWS
Directions to property:
DCHD (6-82)
Allow 5 days for processing