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10 '.. -
�Q, DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:lssued in Compliance With Article 11 of G.S.Chapter 130a
"Sani arySewage Systems Permit–Nurnber
Name o 68,47)
Location '�/�/ �� !C/� /� rC'/�✓,r -��/l'�!�` ?�/ Y��. !`J� lj nc i�lti
Subdivision Name Lot No.' Sec. or Block No.
Lot Size House / Mobile Home _ Business Speculation
No. Bedrooms No. Baths No. in Family —
Garbage Disposal YES E] NO E] Specifications for System:
Auto Dish Washer YES [:] NO ❑ q� Y��/�//
Auto Wash Ma.hine YES.❑ NO E:] 01 /�
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.
�l4
ImP rovements P Y permit b
—
*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 —�–O �-
j l
r
1 �
Certificate of Completion C- F9 Date J �a
•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.
L -
DAVIE-.COUNTY HEALTH .-DEPARTMENT ;
,- - IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ,
*NOTE.Issued in Compliance With Article 11 of G.S.Chapter?!30a
an'taSewage Systems. .' P er itb r_
�4
Date NO
Loca ion \
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home Business Speculation
No. Bedrooms .No. Baths No. in Family _
Garbage Disposal YES ❑ NO ❑ Specificat'9ns r tem:
Auto Dish Washer YES ❑ NO ❑ —
'',Auto Wash Ma.hive YES ❑ NO ❑ f
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.
l i
.4
• 1 4 • /,4/!
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. or 1:00-1:30 P.M. on day of completion. Telephone Number 704-634-5985.
Final Installation Diagram: System Installed by
I <.
-960 fG�
'S
Certificate of Completion C' � - 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 9
NAME
10E C/ A�i 0 a/A- F
PHONE NUMBER �/a -�/ `9
ADDRESS �' "?d --7"gF SUBDIVISION NAME
SUBDIVISION/LOT#
DIRECTIONS TO SITE c ,,r,( G4 vz 2/✓ !� a� � dh
le
DATE SYSTEM INSTALLED
NAME SYSTEM INSTALLED UNDER
A �c terse
SPECIFY PROBLEMS OCCURRING �--
DATE REQUESTED
-9-9 - INFORMATION' TAKEN BY G���