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2537 Corntzer Road Lot 21. Permit F 2. Address APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT i2 Davie County Health Department f'}` Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. .L_Home Phone By C� r S �, �' ti Business Phone 7e0'_5-- D /S 3. Property Owner if Different than Above Address 12± --1' 1qjve. w c c� 4. Permit To: a) Install ✓Alter Repair b) Privy Conventional zZ Other Type Ground Absorption c) Sub -Division 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 3*rX a-9/ Bed Rooms__ Bath Rooms _r 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 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 161) X �LOb b) Land area designated to building site -+y ii r t 161— c) Sewage Disposal Contractor 'nH-S 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? A,14 What type? This is to certify that the information is correct to the best of my knowledge. -_5 _Aj Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: _—tt,t.e_ DCHD (6-82) 0 I DAVIE COUNTY HEALTH DEPARTMENT LAI Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name 45 Date Address Lot Size FAr.TOPR ARFA 1 ARFA 7 ARFA R ARFA A Topography/ Landscape Position S S S S ® PS PS PS U U U U !) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) <::�> PS PS PS U U U U 1) Soil Structure (12-36 in.) S S S Clayey Soils rqm:� PS PS PS U U U U 1) Soil Depth (inches) S S S S PS PS PS U U U U i) Soil Drainage: Internal S S S A;�' PS PS PS U U U U External S S S S C17> PS PS PS U U U U i) Restrictive Horizons Available Space S S S S � PS PS PS U U U U 1) Other (Specify) S PS S PS S PS S PS U U U U !) Site Classification U—UNSUITABLE Recommendations/ Comments: S—SUITABLE ",P,.S—Provisionally Suitable Described by O •`n^�N- iTitle61�rt,_� Date SITE DIAGRAM i� I �P� 3 X DCHD (6-82)