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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
^�IOii�lssuediot-ompflance With Article 11 of G.S.Chapter 130a
- � Sanita sewaey
�S stems
_ Permit Number
d �9
Name �p J p/'P- ate /S s.. C 3 7 5
Location fo� eq,1 •C ��
Subdivision Name Lot No.
oSec. or Block No.
Lot Size House Mobile Home Ir� Business -- Speculation
No. Bdrooms o2 No. Baths No. in Family —
Garba
IS a Disposal YES p NO Specifications for System,-'--",,,
Auto Dish`Washer »YE$ p NO [� i
Auto Wash Ma.hine YES''-0'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 ort,he intende use change.,
'. All �F�
t;
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
Certificate of Completion/ Date, 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
,the
for any.given period of time.
=� DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*1�TEl ssu4d in -ofn Woce With Article I I of G.S.Chapter 130a _ _...
Saoltary/Senagg Systems _/ Permitpi gibber
Name - � ate
Location A2 Cl
Subdivision Name Lot No. Sec. or Block No.
Lot SizeC2 _ House Mobile Home Business -- Speculation
No. Bhdrooms No. Baths o. in Family
. —T--
Disposal YES.p NO Specifications for Systerrh11�ti�\
Auto Dish Washer YES p NO
Auto Wash Ma^.hine YES" NO p
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 ohhe i tended` se change.0.
l
f
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 —�
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 C0�4r
/ /APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME L PHONE NUMBER,�/� �-� ���
ADDRESS SUBDIVISION NAME
LOT#
DIRECTI NS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS o2 NUMBER PEOPLE SERVED
TYPE WATER SUPPLY &i .Oxz SPECIFY PROBLEM OCCURRING
1 DATE REQUESTED��S/0'-:� INFORMATION TAKEN BY //0 //
This is to certify that the information provided is correct to the best of my knowledge,and that nderstand I am responsible for charges incurred from this application.
ISIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93