P7919 Hwy 801SDAVIE COUNTY HEALTH DEPARTMENT"" ` _
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION S 0 ,00)
'NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
Sanitary Sewage Systems _ Permit' Number
NameQ s - ;�i-r—^ cz,s'tR-2-- Date N2 7919
Location — — C�g- , oc�<.sytit1�O)I
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 Ef Specifications for System:
Auto Dish Washer` YES NO [Ox %� 1 ,t S`�, ��
Auto Wash Ma^hine YES NO f
Type Water Supply -- C o" ---
'This permit Void if sewage system described below is not installed within',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. 4 Y
i
Improvements permit byc-_��\J�-'�
'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: 704-634-6986. 87(60
Final Installation Diagram: System Installed by —L�—
F �.
C
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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r wu 0 �Y
-DAME COUNTY HEALTH DEPARTMENT''r'
,�..-.- IMPROVEMENTS, PERMIT AND CERTIFICATE OF' COMPLETION �J
,'NOTE; Issued in Compliance With Article II of G.S. Chapter 130a r
r Sanitary Sewage Systems Permit Number
r. Name"` �.s �4 Date _ N2 791 9
Location —�_
/ -
Subdivision Name `� (r.o`N Lot No. Sec. or Block No.
Lot Size �_ r -" —_ House — Mobile Home — , Business -- Industry
No. Bedrooms —.No. Baths No. in Family Public Assembly Other
Garbage Disposal YES 0 NO Specifications for System: __:`�•:
Auto Dish Washer YES pNO d , x �(
C�
Auto Wash Ma^hine YES 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
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM.
sr��
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
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 ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME AY`mes 3- 1-;', , by �Os\ems PHONE NUMBER
ADDRESS ky, SUBDIVISION NAME
cs v� \� . �. LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED —T NAME SYSTEM INSTALLED UNDER �-
TYPE FACILITY h, C1aRnQ NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED ,, �J -T� INFORMATION TAKEN BY \
This is to certify that the information provided is correct to the best of my
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1193
for all charges incurred from this application.