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"3 DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
anitary Sew a Systen) f�c Permit Number
NameY/�/,nliC SSU' �"�"/ '�%!� ,�D to �� 0 7 8 6
Location �� s u a/C el 'a
I6��✓ � �v�r�l:��Lo�,3J
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home L/ Business -- Speculation
No. Bedrooms "� No. Baths `� No. in Family —
Garbage Disposal YES ❑ NO ❑ Specifications for VSystem: .
Auto Dish Washer YES ❑ NO ❑ /G ���1 a��
Auto Wash Ma shine YES ❑ NO ❑
Type Water Supply ---
a "This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit'is subject to revocation if site plans or the intended use change.
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: System Installed by —uoa �ow'o r
f^
�6 U-S
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.
It 1P
DAVIE COUNTY HEALTH DEPARTMENT
r IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Articled of G.S.Chapter 130a
..-Sanitary Sewage Sy ste s j<< ..�, Permit,.�l �er
Namey' ' !: p Date r D_
.��--;? '" �,� � X../!.('�;/ "' ��y _.f /V VLGT..�/.%L'G�..l.% '. Q'ni {/ fC•'C��''l"�/i'�✓%-�
Location-
Subdivision Name Lot No. Sec. or Block No.
Lot Size �� House _ Mobile Home _� Business Speculation
No. Bedrooms .No. Baths, No. in Family _
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑ /� ' ^�1�any
1
Auto Wash Ma thine YES ❑ NO ❑ `�
Type Water Supply
*This permit.Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
__---
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: System Installed by "� �� T—
T19
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 givenperiod of time.
i DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME l'l GU p' PHONE NUMBER��� �-3'�y�
ADDRESS f 'y � 7 G� '" N SUBDIVISION NAME
/e v`;7dSSF" LOT #
DIRECTIONS TO SITE ?
DATE SYSIk NSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge,and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1193