157 Oak Tree Drive Lot 137kj./ i
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.
1. Permit Requested By -4 �A-o'
2. Address R 9'o—
td , it -3 %o-- 34 Lark , w
Home Phone !ZQ/W - 3;-7
Business Phone
3. Property Owner if Different than Above 46 W �3rr T-469
Address _Z±2�7 File— 64 Ks .C,a,r,F NGtJ CIA vP1.aj0 ?N
4. Permit To: a) Installer Alter Repair
b) Privy ConventionaIX Other Type
Ground Absorption
c) Sub-DivisionP-41914-,) AG t3 Urs Sec. Lot No. 137
5. System used to serve what type facility: House Mobile Homed Business
J
b) Number of people IndustryOther
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions c2 y X '`fl
Bed Rooms— 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 hou
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 X
b) Has the water supply system been approved? Yes. No
9. a) Property Dimensions ADO, 7 3 X 794, 5-3 K I!Vc- b X 10 9, ZJ
b) Land area designated to building site Jr 0 Xa--
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? 'V
What type?
This is to certify that the information is correct to the best of my knowledge.
Date A615;,V0,qQwv4r Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: n 1 ���
� y f w6 Q /� Ov{-� �-�c4Qa-�-�, � G� �t
DCHD (6-82)
04'4 -111W
3 :s� Yz
Name—
Address
ame Address
d
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size
FAr.TnRS APPA 1 ARFA 9 AREA 3 APPA 4
Topography/ Landscape Position
9)
S
S
S
PS
PS
PS
PS
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
U
U
U
I) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
p
PS
PS
PS
U
U
U
U
Soil Depth (inches)
S
S
S
PS
PS
PS
U
U
U
U
i) Soil Drainage: Internal
S
S
S
PS
PS
PS
U
U
U
External
S
S
S
ps
PS
PS
PS
U
U
U
i) Restrictive Horizons
---'—
Available Space
S
S
S
S
PS
PS
PS
U
U
U
l) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
Site Classification
U—UNSUITABLE
Recommendations/Comments:
Described by _
SITE DIAGRAM
DCHD (6-82)
S—SUITABLE PS—Provisionally Suitable
Title 5/ 7;P -11V Date