446 Juney Beauchamp Rd (2) x ' 04
5 t DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTEIssued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage S gtemsQfl,9,�c lv�i:�a/'r'�'' �7 Permit Number
Name ---Date /—, "!-S� N2 7959.
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size _---- House Mobile Home :-- Business -- Industry
No. Bedrl oms �2 —.No. Baths No. in Family Public Assembly Other
Garbage Disposal YES ❑ NO 0�
� Specifications for System:
Auto Dish Washer YES ❑ NO Er
I I I,-V6
Auto Wash Ma-hive YES p NO y
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.
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 Installlation Diagram: - System Installed by ✓c� -
C
a
Fill to
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.
' -. "M:,. . ,•c.,.� ., -.-.'v rr._... ,,�r ay .v.,;.5.'1arys-t-<fi :ri,u;,.t;"b' . �- a `-s:7:.ti-,...—_'.`s.-i s:`:-..w a..-.: � 'L� ..._ `<_6�.,: .,ry' ti - .,.eti rc
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
NOTE:issued in Compliance With Article I I of G.S.Chapter 130a
Sanitary Sewage Systems 'i.;/'� lei#. Val, Permit Number
; :;r
Name Date N� 7959
�' r ' } //C- ca. c ; „--- /" -J5
"(7
Location Z2
Subdivision Name Lot No. Sec. or Block No.
Lot Size — House _ Mobile Home: Business -- Industry
No. Bedrooms c:2 —.No. Baths No. in Family �' — Public Assembly Other
Garbage Disposal YES ❑ NO p' Specifications for System
Auto Dish W�sher YES ❑ NO
Auto Wash Mia^hine YES ❑ NO
Type Water Supply
'This permit Void if sewage system described below is not installed within 5 years from date of issue.
r.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.
f(f r 'I
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 P1.M. or 4:30-5:00 P.M.on day of completion.Telephone Number: 704-634-5985.
Final Installati Dn Diagram: System Installed by
Xq
c� u S •o e � �i
1=�I I •'t tJ B
y
Certificate of Completion __. Date _
'The signing f 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 �C� PHONE NUMBER
ADDRESS SUBDIVISION NAME
�l6 Agm it±�,0 xel �� ��r LOT#
DIRECTIONS TO SITE >�� �� S�✓o�.+�5 ' %n! .J���
DATE SYSTEM INSTALLENAME SYSTEM INSTALLED UNDER
TYPE FACILITY_,40-e NUMBER BEDROOMS oC NUMBER PEOPLE SERVED
TYPE WATER SUPPLY C (� SPECIFY PROBLEM OCCURRING
DATE REQUESTED � -S INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge, t I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1193