125 Lois Ln DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT ,AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article II of G.S.Cha ter 130a
Sanitary Sewage Systems �1 (w Permit Num&-0,U
-0,U
Name_� G2 rn /'L7 Jtiis'1f/ �%Q Date _G' '"��f N0 7504
C.
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size /1-211" House Mobile HomeL-"� Business -- Industry4
No. Bedrooms .No. Baths No. in Family_,t!_— Public Assembly Other
Garbage Disposal YES ❑ NO p` Specifications for System:
Auto Dish Washer YES ❑ NO l ,
Auto Wash Ma;hive YES 2-'NO F] /ILG�
Type Water Supply _ AfIx ---- -Fea- /'1 4J sv
*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.
n
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 z �
Certificate of Completion Date y! s
•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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT 1
• Davie County Health Department 1
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Re uested B
Mailing Address X/ :Z/ Home Phone 1�f�
dZV✓ /t/.l Business Phone
2. Name on Permit if Different than Above
3. Application for: a General Evaluation 2rSeptic Tank Installation Permit
4. System to Serve: ❑ HouseMobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms ZWashing Machine
No. of Bathrooms ❑ Dishwasher
Dwelling Dimensions ❑ Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: ❑ Public 2-15'rivate ❑ Community
8. Property Dimensions /We Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No
If yes, what type?
'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property:
S )pie,
This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurred from this appl' ation.
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE QN ABOVE DESCRIBED PROPERTY
Fanddisposal
ECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
ked Box#2,the rest of this form MUST be completed by the owner or a person authorized by the owner:
ve consent to the authorized representative of the Davie County Health Department to enter upon above described
cated in Davie County and owned by
all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
system.
DATE SIGNATURE
DCHD(1/93)