P7983 Cotten Ln O - _ 6
`�'• `
A , DAVIE COUNTY HEALTH DEPARTMENT
lC �' IMPROVEMENTS PERMIT AND. CERTIFICATE OF COMPLETION
PC
., NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
Sanitary Sewage S stems J" �,/ �l Permit Number
Name.--�1-/v n 3 S11;A;,+ i�' Date : _/,5 - 0 .7983 .
Location %J �Il �p /'
11
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 � Specifications for System:
Auto Dish Washer YES ❑ NO Q-'
Auto Wash Ma^hine YES prNO
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
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM.
f
permit /
Improvements• pe t 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 ,lifl� 7
._ ,
U
Certificate of Completion __ ate
'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.
i_
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
+NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
Name Date '1 ,;%' i 4 _ 1 9 8'3
. ...Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House — Mobile Home ---_ Business -- Industry
No. Bedrooms c-2 —.No. Baths --/-- No. in Family 7 — Public Assembly Other
Garbage Disposal YES p NO per'' Specifications for System:
Auto Dish Washer YES p NO -r
Auto Wash Ma^hine YES 2-'NO p
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
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM.
k
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
El
Y
D
D
Certificate of Completion /a'� __ 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.
f APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER
�'- Davie County Health Department n
Environmental Health Section
P. O. Box 665 1�frtc
Mocksville, NC 27028 APR — 5 IM
1. Application/Permit Requested By. ! ky /e SO, /�C e�Deli
ENVIRONMENTAL COJI HEALTH
� E COUNTY
Mailing Address -360 �• /�� S>i2( Home Phone '--
`� C C ;?%o,-1r Business Phone 2d 9-�3 V,Ze e
2. Name on Permit if Different than Above
3. Application for: d General Evaluation U1481 ptic Tank Installation Permit
4. System to Serve: UA o-u-se ❑ Mobile Home ❑ Place of Public Assembly
❑ Business . ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
❑ Basement/Plumbing
No.of People ❑ Basement/No Plumbing
No. of Bedroomsashing Machine
No. of Bathrooms / ❑ Dishwasher
Dwelling Dimensions ❑ Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers Water Usa 'gures
7. Type of water supply: ❑ Public Private ❑ Community
8. Property Dimensions (01• // Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes o
If yes, what type?
'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:
i3aa� &1vAI -Wle
Tv2,Aj /��71- ex- r/eoy live - 1401145,a7
Zl
N
v cam' %S• Gt`wC' d Lvc.'4-�^J
This is to certify that the information provided is correct to the best of my knowledge, and I u and I am responsible for all charges
incurred fromth' application 1
DATE —STGWk URE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
Fandd
ECK ONE: ❑ 1. 1 OWN the property. ❑ 2. I DO NOT OWN the property.
ked Box#2,the rest of this form MUST be completed by the owner or a person authorized by the owner:
ve consent to the authorized representative of the Davie County Health Department to enter upon above described
cated in Davie County and owned by
all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
al system.
DATE SIGNATURE
DCHD(1193)