325 Yadkin Valley Rd Lot 7 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665 '6
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name •6447Ay ,t ew /�J:i.O- G•Ty.1r%!��• -K& X2 Z,21---J Date
Address - -?-v• cS`V 7 yY Lot Size 3• .P.riu.,
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position SS S S
eM:> PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) 40-fs-> ® PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils (LIR-S-1 ® PS PS
U U U U
4) Soil Depth (inches) S S S S
® yy ® PS PS
U U U U
5) Soil Drainage: Internal S S S S
e5pc2m PS PS
U U U U
External S S S S
C=ES> PS PS
U U U U
6) Restrictive Horizons �/�� � �la�
`'"7 4 f
7) Available Space S S. S S
PS PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE S—Provisionally Suitable
Recommendations/Comments: i — o-Paa ,n,dz tg
Described by Title Date 2`10-80f
SITE DIAGRAM
a4�1.3 n•
S°
2
q5 sa�.�a
Sa� 4''
2
DG. 2o'
243 .e3
DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT t
Davie County Health Department ��,t '1
Environmental Health Section f
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone jiL32/--34� 9"
1. Permit Requested By Jn_..•tiGS el_� Business Phone
2. Address - lk!L/
3. Property Owner if Different than Above
Address �O��n r/O1/cti /��. Zo7� � cf •��� 77 c'.
4. Permit To: a) Installs Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division 4---- 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 ?c24 /
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)
7. Number and type of water-using fixtures:
commodes s urinals garbage disposal acs
lavatory 3 showers / washing machine ,�-
dishwasher 1 sinks
8. a) Type water supply: Public ✓ Private Community
b) Has the water supply system been approved? Yes ✓ No
9. a) Property Dimensions 2_�-L x S ,(/'
b) Land area designated to building site _j
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.
c
Da et Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
'0��e : �ecr/ sic 1�1�^-- .of c�ddfr�s !�'1/f (,Z•�-7�ved Sz�`�o-7L.
7e-
-74
y
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
SITE EVALUATION CONSE14T FORM
INSTRUCTIONS/PREREQUISTES
1. Complete the form below and return it to the Davie Co. Health Department.no s-�ttfer
2. Along with the form, xemit the amount due as shown on enclosed statement ,-
3.
tatement 3. Carefully follow the procedures as outlined in the enclosed "Information
Bulletin".
4. Notify Health Department upon completion of item number 3.
NOTE: ALL THE ABOVE MUST BE DONE BEFORE A SANITARIAN WILL BE ABLE
TO BEGIN THE REQUESTED EVALUATION.
DETACH HERE AND RETURN TO THE(DAVIE COUNTY HEALTH DEPARTMENT,P.O. BOX 57)
(bIOCKSVILLE, N.C. 27028)
DAVIE COUNTY HEALTH DEPARTYXNT '
SITE EVALUATION CONSENT FORM
LOCATION OF PROPERTY: DATE RECEIVED
C�Q ice• c/v Iley x cl • (office use only)
-7
yeses no (1.) I am the owner of the above described property.
yes no (2.) I am not the owner of the above described property, however, I
j certify that I have consent from ,owner to
11 owner's name
obtain a site evaluation by the Health Department for the purpose
of determining the suitability for a ground absorption sewage
disposal system.
yes no (3.) I hereby give consent to the authorized representative of the
! Davie County Health Department to enter upon the above described
1..__. property and conduct all testing procedures necessary to
determine its suitability for a ground absorption sewage
disposal system.
T aa
DATE
IGNAT RE
(4.) T hereby authorize the Davie County Health Department to release
site evaluation results from the above described property to the
following:
Owner Only
J Owner's designated representative
2 / Anyone requesting results
D Only those listed below
SIGNATURE