329 Oakland Avenue Lot 124r.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name DAV' C 12-V
Address P0, Cor ;?(Oz -
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Date Ll— Z t ~ R ?
Lot Size' •X 7-0'69 /-r x 17s
AREA 3 AREA 4
Topography/ Landscape Positions
`sem
S
S
'YPS
PS
PS
PS
U
U
U
U
'.) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
�
(1-5
PS
PS
U
U
U
U
1) Soil Structure (12-36 in.)
Clayey Soils
S
IC27D
S
C --ED
S
PS
S
PS
U
U
U
U
g Soil Depth (inches)
Q
0
S
S
PS'
PS
PS
PS
U
U
U
U
�) Soil Drainage: Internal
�
@�
S
S
PS
PS
PS
PS
U
U
U
U
External
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(:E%> -
S
S
PS
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
Available Space
S
PS
S.
PS
S
PS
S
PS
U
U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
1) Site Classification
U—UNSUITABLE
Recommendations/Comments:
S—SUITABLE ' PS—Provisionally Suitable
Described by �C� Title � Date
SITE DIAGRAM
DCHD (6-82)
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
2. Address
me Phone %1A 7
s`iness Phone & T�f 6
3. Property Owner if Different than Above
Address
4. Permit To: a) Install- Alter Repair
b) Privy Conventionall:::�'__ Other Type
Ground Absorption
c) Sub -Division t""' 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 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
lavatory
dishwasher
urinals
showers
sinks
garbage disposal
washing machine
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No�
9. a) Property Dimensions
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? 4WZ
What type?
This is to certify that the information is correct to the best of my knowledge.
Date O er Signature ".Z4-teRZZIZ�
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND L AL LAWS
Allow 5 days for processing
Directions to property:
49,
zoo
DCHD (6-82)
Davie County Health Department
X36 Environmental Health Section
P.O. Box 848 Ift
1210 Hospital Street�'
OU �� Courier #: 09-40-06
Mocksville, NC 27028
Phone: (336) - 753 - 6780 Fax: (336) - 751 - 8786
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) Replacement Remodeling Reconnection
u1� �I�
Name:O ��� ` Phone Number ✓v� - {Herne)
Mailing Address::; -2c1 a v nWork) /
Email oQ CC . %
0
Detailed Directions To Site:
Aw . 1Ycq� (Ry- is P - I --)-i (-ems
Property Address: ��I-Ci CL K" Q"ANQ M0Ct1,(VMP N C a-
Please Fill In The Following Information About The EXISTING Facility:
(jo-
Name System Installed Under: Type Of Facility: _�ra I 10
Date System Installed (Month/Date/Year): Number Of Bedrooms: �— Number Of People: 3
Is The Facility Currently Vacant? Yes o If Yes, For How Long?
Any Known Problems? Yes ®o If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: jrQ1A 1 V Number Of Bedrooms: Number of People
Requested By: (.0 Date Requested: (9 ' c '
(Signature)
For Environmental Health Office Use Only
Approved 1 Disapproved s
Comments:
y
Environmental Health Specialist, " a 'P �. �,�� P L ; Date:
*The signing of this form by the Environmental Health Staf£ns in no way intended, nor should be taken as a guarantee
(extended or limited) that the on-site wastewater system will function properly for any given period of time.
Paid Bye
Account #:
Cash) Check Money Order # . Amount:$
Date:
Received By:
Invoice #: 1