766 Sain Road Lot 84 .
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone -
1. Permit Requested By6:�OLZu1f/ �'•>k-mss Business Phone
2. Address
3. Property Owner if Different than Above
Address -Sol /V 4/7
4. Permit To: a) Install v Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division Sec. Lot No. 09
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people 3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms .3 Bath Rooms / ,/;–I— 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 Z urinals
lavatory 2/ showers
dishwasher sinks —
8. a) Type water supply: Public_ Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions
garbage disposal
washing machine
b) Land area designated to building site
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.
.2--Z-,-F�
Date
Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-82)
Name—
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size
FACTORS AREA 1 AREA 2 AREA 3 ARFA d
1) Topography/ Landscape Position
S
S
S
PS
S
PS
U
U
U
?) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
S
PS
S
PS
U
U
U
U
3) Soil Structure (12-36 in.)
Clayey Soils
SS
�
P
PS
S
PS
U
U
U
1) Soil Depth (inches)
S
S
S
PS
S
PS
U
U
i) Soil Drainage: Internal
S
IPSO
S
PS
S
PS
�
U
U
U
External
S
pg
PS
S
PS
S
PS
U
U
i) Restrictive Horizons
Available Space
S
PS
S
S
PS
U
S
PS
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
1) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/ Comments: —� 1
Described byTitle Date
SITE DIAGRAM
v �'
DCHD (6-82)