374 Harper Rd Y (0
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 Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name - . 5 Date {' � 3!J
j
Location
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Subdivision Name Lot No. Sec. or Block No.
Lot Size Z-2 House Mobile Home �' ~ Business Speculation
No. Bedrooms No. Baths �� L2 No. in Family
Garbage Disposal YES ❑ NO ❑
] Specifications for System:
Auto Dish Washer YESNO [jIZ
/
y,q uto Wash Machine YES p NO ❑
' Type Water Supply
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*This permit Void if sewage system described below is not inst lled within 36months from date of issue.
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Impro ements permit by
*Contact a representative of the Davie County Health Depa'rment for i I inspecti n of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telepho a Number: 04-634-56$5.
Final Installation Diagram: )stem nstalled b
c,
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.
APPLICATION FOR SITE EV )TION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
_ CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
n p Home Phone- 9 Z�
1. Permit Requested By `�"/eS �5. J, S Business"'Phone L- o0-X?Z- it=
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2. Address V, 3 Bow �F"'� twnCe A 7604
3. Property Owner if Different than Above
Address /O
4. Permit To: a) Install ✓Alter Repair'
b) Privy Conventional/ Other Type
Ground Absorption r
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Homes
IndustryOther
b) Number of people 2-
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions JZ X'6j(5-
Bed Rooms—Bath Rooms Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes Z-- urinals garbage disposal
lavatory Z showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private__JZ Community / v
b) Has the water supply system been approved? Yes NoJ� Well �Ae C/1,
9. 'a) Property Dimensions (,!Chef -a"49"o r goon ,x
b) Land area designated to building site 1
c) Sewage Disposal Contractor_ __C-0x0 S e,h/-�� �Cryi/� 1'el- r e'i
10. Do you anticipate any additionsr expansions of the facility this sewage system is intended to serve? V
What type? ZQ h 1J/Cyh T'D �2�/��� �� zzelhoopn P/We till
This is to certify that the information is correct to the best of my knowledge.
13- k4l
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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