109 Maplewood Ln ( i'`atili!'�+A'F,^i.lf+ '".r ! t-�r .... :. .,...- H... ,,_..,,,;,,_:,y,..r1'., µ:.,.•.j,:: y'•tT'cri _.. �
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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a IMlICHS E)
A13anitary Sew ge Systems� r., � Permit Number
Name D.� fp1�tr�E' /119 6�f0_C//'r �/k, Date 9 Si N
° 71TT3
Location �0 12/% ' •�fa /`-�� �PI % D� •Jli,a�/J, !c�!— �"
Subdivision;Name Lot No. Sec. or Block No.
Lot Size House Mobile Home Business -- Industry
No. Bedrooms .No. Baths No. in Family _ Public Assembly Other
Garbage Disposal YES p Nor0— Specifications for System:
Auto Dish Washer. YES NO p
Auto Wash Ma^hine YES [j 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 or the intended use change.
Improvements permit byJO/Z
�
*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
1
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.
v �X D
DAV'IE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ;
*NOSE:Issued in Compliance With Article II of G.S.Chapter 130a SE£ �97Tr;rCH�k�
anitary�Sew ge Systems,�/� ,/ _... ✓I�j Permit Number
Name V 11617�' /11 �dOf/Pr 1421N
.^ Date
/ /f-� /-,r��^ %/ � 7 T T 3
-�
LocationX1-124 TY. A el
k
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business _— Industry
No. Bedrooms —.No. Baths No. in Family _ Public Assembly Other s
Garbage Disposal YES ❑ NO pr
Specifications for System:'
Auto Dish Washer YES NO ❑ f,
Auto Wash Ma shine YES // 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 or the intended use change.
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
_.LSV
f
Certificate of Completion _/ Date
P
"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.
Y
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
' APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME PHONE PHONE NUMBER
ADDRESS ,Zt� 9 4`T AS72Z1 ,^ ,ZZ4- ," SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE 6 6'
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY-,& A4 NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING �C'r� 1 ✓�
7 e
DATE REQUESTED 4D-o2 yINFORMATION TAKEN BY ti✓
This is to certify that the information provided is correct to the best of my knowledge,and that I understand I am responsible for all charges Incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93