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DAVIE COUNTY HEALTH DEPARTMENT
f' / IMPROVEMENTS PERMIT AND .CERTIFICATE OF COMPLETION
*NOTEAssued in Compliance With Article I I of G.S.Chapter 130a
San't Sewage Systems Permit Number
Name z�7 , �o.,i f71ek /�U,f�Date NO 6331
Location
Subdivision Name Lot No. Sec. or Blork No.
Lot Size House Mobile Home � Business Speculation
No. Bedrooms — No. Baths No. in Family
Garbage Disposal YES ❑ NO Q— Specifications for System:
Auto Dish Washer YES NO ❑ I
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.
B
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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 —17."'_S
30' 3v' 3 0
Certificate of Completion `V• Date k
<5 .
*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.
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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION .,
r� *NOTE:Issued in Compliance With Article I l of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
Name -1z� z 1e,;c �/Date No 6339.
Location 1,�'r.r fJ � � ,r,. �/i,`1c1.r� .� i % � �' � i, Art
fi L'&-
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home Business Speculation'
No. Bedrooms _No. Baths No. in Family
Ginnwage tSisposal YES ❑ NO Specifications.for System:
Auto Dish Washer. YES p NO ❑
Auto Wash Ma,hine YES [ NO r-1 / v et
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.
}
4
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
I
H I
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.
r
' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
-�, Davie County Health Department
•. Environmental Health Section
P. 0. Box 665
Mockoville, NC `27028
1 . Application/Permit Requested By
Mailing Address �7 �4 "��2b 4�G,'�57�7�����t�
Home Phone ���' �39� Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For: General Evaluation es/Tank Installation
5. System to Serve: House ?"-*M**obile Home 0 Business
Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People _ Dwelling Dimensions
No. of Bedrooms Basement/Plumbing
No. of Bathrooms ` Basement/No Plumbing
lashing Machine 0 Dishwasher 0 Garbage Disposal
7. If business, industry, 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
8. Type of water supply: 2,-F'ublic 0 Private a Community
9. Property Dimensions 4/•/"VC
10. Sewage Disposal Contractor
�;5'1091 ZZZ'VJf2--
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? Q Yes 0 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.
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 application.
Date Signature
Directions to Property :
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DCHD (10-89)