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DAVIE COUNTY HEALTH DEPARTMENT
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IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION � -
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
Name— *J vs Date a U 9 3 NO 70.28
Location \� o 5 7 o mks v �\ N e.
Subdivision Name Lot No. Sec. or Block No.
Lot Size �vJ House Mobile Home _T Business o G Speculation
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No. Bedrooms a' No. Baths No: in Familyr-
Garbage Disposal:. YES ❑ NO El NSpeqifi ationss for System: - Ra. �y
Auto Dish Washer YES p NO ❑ sem .
Auto Wash Ma^hine YES u� NO,
Type Water Water Supply-
*This permit Void if sewage system,described below is not installed within 5 years from d """
This permit is subject to revocation if site plans or the intended use change. c. _
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,Improvements permit byiZ�--
*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: Syster li lgstall d by
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-r�ertific a 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.
w` DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION'
*NbtE:Issued in Compliance With Article 11 of G.S.Chapter 130a
Sanitary Sewage Systems, PermitAuTber
Name � <: L,> ,.�\ _ Date " 1�., NO
c
Location - —
Subdivision Name Lot No. Sec. or Block No.
t'
Lot Size '`'5 House Mobile Home _T,Business -- Specylation
No. Bedrooms—.. .No. Baths No. in Family J � '-
Garbage Disposal YES ❑ NO ❑ st
Specificatio s f(? Sy%T:
Auto Dish Washer YES ❑ NO ❑ >, ` -'�` }
Auto Wash Ma shine YES .p NO ❑
Type Water Supply __—
*This permit`Void if sewage system described below is not installed within 5 years from da nf;issue�
This permit is subject to revocation if site plans or the intended use change.
1
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 _•
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�d IL
U S Q ! Q r k
/.
Certifica a 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.
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_ DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
• Q 'WORKSHEET FOR SEPTIC SYSTEM REPAIR PERMIT
NAME 1\i�N J Py S PHONE NUMBER
ADDRESS R-* SUBDIVISION NAME
SUBDIVISION LOT#
DIRECTIONS TO SITE
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c� VIS
DATE SYSTEM INSTALLED
NAME SYSTEM INSTALLED UNDER O - ►. �� ��51
SPECIFY PROBLEMS OCCURRINGr.w,
DATE REQUESTED_ _ 3 . INFORMATION TAKEN BY �-
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