234 Pollard Ln (2) °-----•....,..-;a...�,y._..,.+w...:.,.«..{...- yr, - :- - -.-: - _- -:.,.�.,9, "�-`'moi a;...... >.
DAVIE COUNTY HEALTH DEPARTMENT
- IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`NOTE: Issued in Compliance With G,S, of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .19314-.1968) Permit Number
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:7 417
Name Date '
Location �,` ~`z �= 'v' t, 1
Subdivision Name Lot No. Sec. or Block No.
Lot Size 1 � � House Mobile Home — Business -- Speculation
No. Bedrooms L.1
i No. Baths - No. in Family _
Garbage Disposal YES E] NO b Specifications for.System:
Auto Dish Washer YES Q NO Q
Auto Wash Machine YES Qr NO ,Q
Type Water Supply
"This permit Void if sewage syste escribed be of installed within 36 months from date of issue. .
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Improvements permit by --
'Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: vI ystem Installed by C3 •o..� �a �
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Certificate of Completion � Date _
"The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
DAVIE COUNTY HEALTH DEPARTMENT
IMPROMEMENTS PERMIT AND CERTIFICATE OF COMPLETION
t*WTE�-Is9bed ih-Compliahce with G'.S.,of,,,
North Carolina Chapter 130 Article 13c
Sewa
Permit Number
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Nama
' ,-Date ��^. � u '� � 7���^
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Location
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Subdivision Name Lot No. Sec. orBlock No.
�
Lot Size House Mobile Home ____ Business -- Speculation
C,No. Bedrooms No. Baths No. in Family_�_
Garbage Disposal YES [] NO E �-.~`��^ Specifications for System:
Auto Dish Washer E8 � —
� ' ~ `
Auto Wash Machine 'YES '
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Type VVa8*r Supply
*This date of issue.
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Improvements permit bv
`
*Contact a representative of the Davin County Health Department for final inspection of this system between 8:30'
8:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 7O4'G34-G985.
Final Installation Diagram: q System Installed by
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Certificate ofCompletion Date
'The signing of this oedifioobo ahoU indicate that the `system described above has been installed in compliance
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will functi
satisfactorily for any given period of time. ~ `
_
INFORMATION FOR SEPTIC SYSTEM REPAIR PERMIT
" NAM Q�.4,5 \\� �� PHONE NUMBER
ADDRESS �L O�C y�p� SUBDIVISION NAME
SUBDIVISION LOT #
DIRECTIONS TO SITE ch,
DATE SEPTIC SYSTEM INSTALLED
NAME SEPTIC SYSTEM ORIGINALLY INSTALLED UNDER
I
SPECIFY PROBLEMS THAT ARE OCCURRING
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DATE REQUESTED . �� �, INFORMATION TAKEN BY �\\�