1723 Jericho Church Rd =; DAVIE COUNTY HEALTH•DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage TreatmentandDis osal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name ,�\ ��� �.�;. \ e c.�� Date �� - 9 - N� STu�
Locgflon 1�t cl oar. cf
Subdivision Name Lot No. Sec. or Block No.
Lot Size House �" Mobile Home _ Business Speculation
No. Bedrooms _,No. BatF s 2- No. in Family
~'Garbage Disposal YES p .NO
Auto Dish Washer YES NO Specifications. for System:
C)
Auto Wash MachineNO
Type Water Supply _
*This permit Void if sewage system described below is not installed within t months from date of issue.
F-
Improvements permit by
*Contact a representative of the Davie County Health Ddpa?t nt for fi awgi pection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telepho 8:30-
%umber: 704-834-5985.
Final Installation Diagram: System Installed by
bl ,u� loop
LL
0
3b ,
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 HVAL-TW DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
• `NOTE: Issuetl in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit
Number
1 Name arc <;� � � > c_�, Date N2 ,!
Locations `7 1� r�i. `( ILIe Z`.,5
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms _ No. Baths in Family
Garbage Disposal YES p NO ❑ Specifications for System: — sL
Auto Dish Washer YES NO C3Auto Wash Machine l \;YES ;NO p ��v��� �( �-Z, /X 1 ��
Type Water Supply
,0 2rJ ,a
*This permit Void if sewage system'described below is not installed within 6 months from date of issue.
a
1 f ,
j/
jnr provements permit by
*Contact a representative of the Davie County Health Departrfor final�.inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Teleph-o a Number: 704-634-5985.
Final Installation Diagram: System Installed by —�
ooi .,v,;
iL
!4
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.
WORKSHEET FOR SEPTIC 'SYSTEM REPAIR PERMIT
NAME �� 1 PHONE NUMBER
ADDRESS -y' ��-�—'� 7 �/ SUBDIVISION NAME
Al -ksV'-
SUBDIVISION LOT#
C j
DIRECTIONS TO SITE G I
DATE SYSTEM INSTALLED f ��
NAME SYSTEM INSTALLED UNDER
SF ly� a C �q us . �� ctS�IMCJI
SPECIFY PROBLEMS OCCURRING �-
��(l�
DATE REQUESTED INFORMATION TAKEN BY �