153 Granada Drive Lot 100.4k
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested By
2. Address
c 6-3- ?S—
Home Phone
Business Phone y'9 j-/&r'r
3. Property Owner if Different than Above
Address
4. Permit To: a) Install4 Alter Repair
b) Privy Conventional Other Type
Ground Absorption 49
c) Sub-Divisiono& i%.✓rA Sec.��ot o./10 4
5. System used to serve what type facility: House Mobile HomeA-0,"Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions IA Y G
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)
7. Number and type of water -using fixtures
commodes �-
lavatory
urinals garbage disposal
showers '' washing machine
dishwasher / sinks
8. a) Type water supply: Public Y Private Community
101
b) Has the water supply system been approved? Yesy No
9. a) Property Dimensions 6X X
b) Land area designated to building ,site c --A -� �—
c) Sewage Disposal Contractor ._C,itA f As A 7-7_ AEe-
10.
ZE'e-
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 corre the best of my knowledge.
/ -_ �
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
1= 'S
DCHD (6-62)