408 Oakland Avenue Lot 100-101c
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name kdabn'AW W ILI-1NS6N Date to` /I_ Y3
Address Lot Size 266 X you
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
Topography/ Landscape Position
SS
(fa?
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S
PS
U
U
U
') Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
�R
PS
U
U
U
U
1) Soil Structure (12-36 in.)
Clayey Soils
S
dpU
S
S
�
S
PS
U
U
U
1) Soil Depth (inches)
®
-IS
PS
PS
U
U
U
U
�) Soil Drainage: Internal
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1. /
-<�)
S
PS
PS
PS
PS
U
U
U
External
/U�
CSi
t
S
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 Suita le
Described by J{7 Title �1�"Date
SITE DIAGRAM
M
DCHD (6-82)
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home PhoneD $�
1. Permit F
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install ' Alter Repair
b) Privy Conventional Other Type
Ground Absorpt'
c) Sub-Divisiok1Zjec. -3 Lot No.
5. System used to serve what type facility. H use Mobile Home Business
�� IndustryOther
b) Number of people ,�/ �D
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 1¢' ,X 6O'
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 dy7 e
lavatory. -4-0,
dishwasher
urinals
showers
sinks �� P
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes_ZNo
9. a) Property Dimensions
b) Land area designated to building site
c) Sewage Disposal Contractor
garbage disposal
washing machine 4`/7 --e
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? 470
What type?
This is to certify that the information is correct to the best of my k owledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: -
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DCHD (6-62)