6579 Hwy 801S (2)13
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665 RECEIVED MAR 2.5 X87
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested By
2. Address
Home Phone 2 / 2 F
Business Phone %��- 72 7 3Za'/
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 SecLot No.
5. System used to serve what type facility: House Mobile Home—
ome Business
Industry Other
b) Number of people 12-
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions X 3 2 -
Bed
Bed Rooms_,3 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)
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ZelA V e. --I Pe-
�f.�, lav Seq
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7. Number and type of water -using fixtures:
commodes 3 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 20 ,4C2e<
b) Land area designated to building site 2-
c) Sewage Disposal Contractor �� ���DAJ
10. Do you anticipate any additions or expansio s of the facility this sewage system is intended to serve? X/O
What type?
This is to certify that the information is correct to the best of my wledge.
ZZ7/o/ 7 - 4 ;/� /-",,
to Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIA CE WITH ALL STATE AND LOCAL LAWS
���QE➢_�n�o . Allow 5 days for processing
DCHD (6-82)
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
SITE EVALUATION CONSENT FORM
1. Complete the form below and return to the Davie County Health Department.
2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin."
NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO
BEGIN THE REQUESTED EVALUATION.
DETACH HERE AND RETURN TO: Davie County Health Department, Environmental
Health Section, P. 0. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
QA!/D (office use only)
yes no 1. 1 am the owner of the above described property.
yes no 2. 1 am not the owner of the above de cribed property, however, I certify that 1
have consent from — , owner to obtain a
owner's name
site evaluation by the Davie County Health Department for the purpose of
determining the suitability -for a ground absorption sewage treatment and
disposal system. .
yes no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Department to enter upon the above described property and conduct all
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
0
D E SIGNATURE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
DCHD (11 /84)
— Owner only
— Owners designated representative
Anyone requesting results
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name— Date
Address \`� N71 Lot Size �o
FACTORS
ARF: l\ AR4 9-) ARFA(AA l AD=A n
1) Topography/ Landscape Position
c
PS
S
�
S
PS
U
U
U
U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
C PS
ch�'
di)
S
PS
U
U
U
3) Soil Structure (12-36 in.)
Clayey Soils
PS
(t)(PS
S
PS
,- U
U
U
U
1) Soil Depth (inches)
PS
PSPS
�PU
S
U
i) Soil Drainage: Internal
S
CPP
U
U
S
PS
U
External
PS
PS
PS
S
PS
U
U
U
i) Restrictive Horizons
Available Space
pS
PS
P
S
PS
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
1) Site Classification
�= -a S
U—UNSUITABLE S—SUITABLE PS— rovisionally Suitable
Recommendations/Comments:
Described by Title - Date
SITE DIAGRAM
DCHD (6-82)