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936 Greenhill Rd Y,] , .. g-'"�,y ``4t�4 `"..,r.-7�i""g."�Fl-.e`i�k_::� .i"'riF"ht�7iY'{`f:`y.:r,'.1i�'w.,,n..�i<;,:f)t �Pii�.;.�.*"t' -. w �'Ak ,.-•r,•�.,i (/ `XXL rq' DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a S nits Sewa S stem ,I <— w1'✓''° �gP Permit Number ;! WX ate Name-� QLD_ �--- N_ 7787 Location Subdivision Name Lot Nq Sec. or Block No, Lot Size House e _ Business -- Industry- No. Bedrooms No. Baths _— No. in Family 3 Public Assembly Other Garbage Disposal YES ❑ NO ❑/ Specifications for System: Auto Dish Washer YES NO ❑ / Auto Wash Ma shine YES NO ❑ ( �©� � Type Water Supply *This permit Void if sewage system described below isnot installed within 5years 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'M al 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.Telep ne Numb -704-634-5985. Final Installation Diagram: System talled y _ ZV iso 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 IMPROVEMENTS; PERMIT AND CERTIFICATE OF COMPLETION 'Issued in Compliance With'Article I I of G.S.Chapter 130a Sgn_itarry Sewa e s ste < �� '�`��6�' Permit Number . Name�E ', r�i�� ��i� �/ Date N27787 Location Subdivision Name , Lot No. Sec. or Block No. � �Mobile-Nome Business _ Lot Size /`�� House Industry_ No. Bedrooms No. Baths --,/- No. in Family _ Public Assembly Other Garbage Disposal YES ❑ NO C;J� Specifications for System: Auto Dish Washer YES NO ❑ / /�� Auto Wash Ma^hine YES E 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. r r permit b Improvements p y *Contact a'representative of the Davie County Health DepartmenttTo fi al inspection of this system between 8:30- :30 A.M., 1:00-1:30 P.M.or 4:30-5:00 P.M.on day of completion.Teleph ne Numb"4-634-5985. 704-634-5985. Final Installation Diagram: System tailed y l' 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. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT r Davie County Health Department //- Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By '`/c-�^g LID ' err./ C -T& Mailing Address Home Phone 70 Y e,(5 ) 76 7 b (1"1Oc-,k5�i,' Vle Business Phone WO 7(S-4.4?%1" 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation peptic Tank Installation Permit 4. System to Serve: Er'Aouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business- ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home:Subdivision �oN-t Section Lot # ❑ Basement/Plumbing No. of People 3 ❑ Basement/No Plumbing No. of Bedrooms 3 ❑ Washing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served is No. of Sinks No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers �' Water Usage Figures 7. Type of water supply: RrIyubiic ❑ Private ❑ Community 8. Property Dimensions Sewage Disposal Contractor h �� 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? S'Yes ❑ No If yes, what type? 0 el e— 1yl d e%L f3✓-L I If0 o `NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: o f o 10 1��• (moo �-n -�-� I� v�� ko k 5-t. O Kf--, This is to certify that the information provided is correct to the best of my knowledge, and I under tan I am responsible for all charges incurred from this application. DATE SIGNATU CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 1. I OWN the property. ❑ 2. 1 DO NOT OWN the property. If you checked Box#2,the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD(1193)