121 Raintree Road Lot 4DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION /�
Name Z) RICE Date 7'
Address Lot Size
FA r.TnR C
APPA 1 ARFA 9 AREA 3 AREA 4
Topography/ Landscape Position
2)
�'j
a)
5)
6)
8)
9)
C]ED
C93
S
S
PS
PS
PS
PS
U
U
U
U
Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
("n)Qm
PS
PS
U
U
U
U
Soil Structure (12-36 in.)
&
S
4s)PS
S
S
PS
Clayey Soils
U
U
U
U
Soil Depth (inches)
8)
<Er�'
S
S
PS
PS
PS
PS
U
U
U
U
Soil Drainage: Internal
S
S
S
S
PS
PS
U
U
U
U
External
�
ER
S
PS
S
PS
U
U
U
U
Restrictive Horizons
Available Space
S
PS
S.
PS
S
PS
S
PS
U
U
U
U
Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
Site Classification
U—UNSUITABLE
Recommendations/ Comments:
Described by
SITE DIAGRAM
DCHD (6-62)
S—SUITABLE PS—Provisionally Suitable
Title
X �g
Date ! Z6.
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tl
' Ai -'H -ICA ION i0'H :31 i -E LVAL Ur;fION/li,,,•IPHOVE1vlci�j I S PERO/li (
David County Health Department •-/ �! /
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
A Home Phone
1. Permit Requested By J Business Phone
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install ✓ Alter Repair
b) Privy Conventional-jZOtherType
Ground Absorption
c) Sub -Division Lahxe EA -4m, 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 -
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 3 urinals garbage disposal
lavatoryshowers washing machine -1
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No-
9.'a)
o9.'a) Property Dimensions /o75: " x J'go "k 7-T "x s -r-&/ x /A9
b) Land area designated to building site
c) Sewage Disposal Contractor /n r,, .., u /V ix'n ki jz.;I ti'. 'we% X) .!c .
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.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
OcHn (8.82(