146 Brookdale Road Lot 13 Section 20
Address
CA(Tn0Q
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date 3-1445
Lot Size
AREA 1 FP-Ij- APPA 9 AREA 3
AREA 4
) Topography/ Landscape Position
0,PS
2)
3)
A
5)
8)
9)
S
S
S
S
PS
U�
U�
U
U
Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
d3)
S
S
S
US
US
Soil Structure (12-36 in.)
Clayey Soils ""
S
<f5
S
PS
S
PS
U
Soil
Y
) Depth (inches)
S
d)6
S
S
PS
S
PS
U
U
U
U
Soil Drainage: Internal
S
S
S
PS
S
PS
U
U
U
External
S
PS
PS
PS
U
U
U
U
Restrictive Horizons
A:"
A6)
,33_._
') Available Space
S
S
PS
U
S
PS
U
Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
Site Classification
S
S
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:] fl'"
Described by Title Date 3 - )� `�3
SITE DIAGRAM
DCHD (6-82)
DAVIE COUNTY HEALTH DEPART,"IENT
SITE EVALUATIO14 CONSENT FORM
INSTRUCTIONS/PREREQUISTES
1. Complete the form below and return it to the Davie Co. Health Department.
2._
3 llow the procedures as outlined in the enclosed "Information
Bulletin".
4. Notify Health Department upon completion of item number 3.
NOTE: ALL THE ABOVE P4UST BE DONE BEFORE A SANITARIAN WILL BE ABLE
TO BEGIN THE REQUESTED EVALUATION.
G&3
DETACH HERE AND RETURN TO THE(DAVIE COUNTY HEALTH DEPARTMENT,P.O. BOX -
(MOCKSVILLE, N.C. 27028)
DAVIE COUNTY HEALTH DEPART1,MNT
SITE EVALUATION CONSENT FORM
LOCATION OF PROPERTY:
DATE RECEIVED
(office use only)
'es no (1.) I am the owner of the above described property.
yes no (2.) I an not the owner of the above described property, however, I
certify that I have consent fromsre-Ne t • Tie-VNg (__.owner to
la 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
property and conduct all testing procedures necessary to
determine its suitability for a ground absorption sewage
disposal system.
3--Z-83
DATE
SIGNATURE
(4.) I hereby authorize the Davie County Health Department to release
site evaluation results from the above described property to the
following:
[_ Owner Only
rj Owner's designated representative
Anyone requesting results
DATE 0 Only those listed below
SIGNATURE
DAVIL COUNTY HEALTH DEPART,'vMIJT
PERCOLATION TEST RESULTS
DATE ii
NAIME `•- et,fI `L ( `L tl
LOCATIM, V R,`Lt4�.W bz7 Ll� r -i l "' 13 3 L b c K
FIIIDII4GS : HOLE 140.
Al
2
4
5
6
LOT DIAD M
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r
MMM- - JTS
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By: /
tAGc
0
DAVIE COUNTY HEALTH DEPARTMENT
ENVIROMMEMAL HEALTH SECTIO14
P.O. Box 57
MOCKSVILLE, N.C. 27028
(704) 634-5985
STATEMENT FOR SEPTIC TA14K IMPROVEMENTS PE&MITS AMD/OR SITE EEVVAALUATIONS
NAP IE [����,V�y e(s,� DATE
ADDRESS C "r' l ��'�� �b P/7�i-� PEIMIT NO.���`P�
vs—sZ':_ — i!�. _ _o0V1, Cg �_r
EXPLANATION OF CHARGE
AMOUNTDUE�CT% SANITARIANS _
PLEASE REMIT THE ABOVE AMOUNT OF RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be completed until payment is received.
Improvements Permit(s) can not be issued until payment is received.