1420 Farmington Rd i
DAVIE 'COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT-, AND CERTIFICATE OF COMPLETION
NOTE:!,:Issued in Compliance with G.S. of North Carolina Chapter 130'Article 13c t
S wage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name �„ ." ,, ,1 -n �.� ��1',�� Date —k �/ G� N2
b2 2Locatio
r
Subdivision Name
Lot No. Sec. or Block No.
Lot Size / t)�'��� House Mobile Home _ Business Speculation
No. Bedrooms No. Baths No. in Family ,,_
Garbage Disposal YES NO ❑
Specifications for System: � `
Auto Dish Washer YES NO
Auto Wash Machine YES NO ❑ G _
Type Water Supply
*This permit Void if sewage system described below is not insta led/wi hin 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 be!yveen 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
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Final Installatio Diagram System Installed by
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C rtificate o o I Bio Date _ 7
*The signing of this certificate shall indic to that e e ed above_has-b a nstalled in compliance with
the standards set forth in the above regu ation, but slat in NO way be talon a§"a gu r�ntee that the system will function
satisfactorily for any given period of time. / L
IF• - APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT /
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
4,1�ome Phone
11. Permit Requested By �� Business Phone 7Vk—Z!K Or 5
Address 42
3. Property Owner if Different than Above
Address
4: Permit To: a) Install�Alter Repair
b) Privy Conventional—4--."Other Type
Ground Absorption
c) Sub-Division Sec Lot No.
5. System used to serve what type facility: House V Mobile Home Business
IndustryOther
mob) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions o2.�6a ►�'�"
Bed Rooms 3 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 3 urinals garbage disposal
lavatory -, showers washing machine
dishwasher sinks
z,-ra) Type water supply: Public �� Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions ZAP°
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify that the information is correct to the best of my knowledge.
v
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to propertV
DCHD(6-62)