582 Gladstone Rd DAVIE COUNTY HEALTH DEPARTMENT
ti IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems 2 . ,�oChs✓- Permit Number
Name �� ��� J _�� �-/Date—�1N2 8201
Location - ��i c-,; .,/✓ v� zT
Subdivision Name Lot No. Sec. or Block No.
Lot Size __ — House _ Mobile Home Business _- Industry
-.No. Bedrooms _ No. Baths — — No. in Family- — Public Assembly Other
Garbage Disposal YES ❑ NO R— Specifications for System`,
Auto Dish Washer YES NO ❑
Auto Wash Ma^hine YES NO ❑ �t�C/��,Y/o7 �� '
Type Water Supply _ zl // -- ---
'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
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM.
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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.,
1:00-1:30 P.M. or 4:30-5:00 P.M.on day of completion.Telephone Number: 704-634.5985.
Final Installation Diagram: System Installed by
r
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.
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DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME l � � � PHONE NUMBER
ADDRESS--' o SUBDIVISION NAME
LOT#
DIRECTIONS TO SITE aiefJO-e,-
DATE
rDATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY a NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY Aze- SPECIFY PROBLEM OCCURRING
DATE REQUESTED INFORMATION TAKEN BY
This is to certify that the Information provided is correct to the best of my knowledge, d that I understand I am responsible or all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1193