P3097 Dalton Rd -At&6-
DAVIE COUNTY HEALTH DEPARTMENT a
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued 'in Compliance with G.S. of North Carolina Chapter 130—Article 13c. t"
Permit Number
Name L Date t` +C t
Location
'Subdivision Name Lot No. Sec. or Block No.
Lot Size f " _" l ``– House `! Mobile Home — Business Speculation
No. Bedrooms No. Baths 1! No. in Family
Garbage Disposal YES ❑ NO per" Specifications for System: %�-��" �' �f• " "' �--
Auto Dish Washer YES p NO ❑ _f1
Auto Wash Machine YES p NO ❑
Type Water Supply , �r a�`:'�..;r _ ,!) - ,' ,�; '�� ! r' • <'
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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Improvements permit by
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*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by
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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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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED..
• Home Phone •
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1. Permit Requeste By U Gee' GJ Business Phone
2. Address -
3. Property Owne if, ifferent than Above
Address
4. Permit To: a) InstallIter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. —Lot No.
5. System used to serve what type facility: House tt//Mobile Home Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions—
Bed
imensions Bed Rooms 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- sing fixtures:
commodes �� urinals garbage disposal
lavatory. / showers / washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community �J
b) Has the water supply syst m been approved? Yes �o
9. a) Property Dimensions
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate�Ia additions or expansions of the facility this sewage system is intended to serve? O
What type?
This is to ertify that the information is correct to the best of my knowledge.
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Date Owner Signa e
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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pass el ,V/
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DCHD(6-82)