261 Childrens Home Rd * 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 - �- �Kfi .,,�Gate �� ti No 7360
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size_ rte;_ House Mobile Home -1! Business°_k- Industry
No. Bedrooms —.No. Baths — -1 No, in Family _ Public Assembly'" Other
Garbage Disposal ""-t) IYES ❑ NO ".-Specificationfor System:
Auto Dish Washer YES p, NO ❑ / �� G�4 ;,� -' �i
Auto Wash Ma^hive YES, NO
Type Water Supply _ y
*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.
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-'Improvements permit
*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.
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Final Installation Diagram: System Installed by
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Certificate of Completion �- est 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 PERM
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,. Davie County Health Department
Environmental Health Section r�
P. O. Box 665 'Nov � n
Mocksville, NC 27028
1. Application/Permit Requested By
Mailing Address 1'�, . �) . Home Phone -
�� Lf,L 4 Business Phone b,3 k/—13(b
2. Name on Permit if Different than Above
3. Application for: ❑General Evaluation Septic Tank Installation Permit
4. System to Serve: ❑ House, Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home:Subdivision Section Lot#
❑ Basement/Plumbing
No. of People �I ❑ Basement/No Plumbing
No. of Bedrooms Washing Machine
No. of Bathrooms Dishwasher
Dwelling Dimensions o'�� - ❑ 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 Usage Figures
7. Type of water supply: ❑ Public CA Private ❑ Community
8. Property Dimensions Sewage Disposal Contractor
9. Do you anticipate additionslexpansion of the facility this sytem is intended to serve? . ❑ Yes No
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:
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This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurred f om Ihis application.
(::A am'YJ
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TQ aE D NE ON ABOVE DESCRIBED PROPERTY
Fhereby
ECK ONE: EA 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
Ifked 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
ail testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
al system.
DATE SIGNATURE
DCHD(lip