350 Baileys Chapel Rd DAVIE COUNTY HEALTH DEPARTMENT j v
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 7r6
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a -7,v ,�
Sanitary Sewage System4J Permit Number
Name •�^n � L ti�S4k'r�/'`�=.moi Date ��=°�-r��(� N2 5870
Location ;�/. �� 1�7' ,f"/i��: ' , 7` ,I J�'. J r.� ✓
;LSO 1"/?,!� .�.���r'�r i' ;�,. _/r :!:• %�� ;`) ..
Subdivision Name Lo Sec. or Block No.
Lot Size `s House Mobile Home _ Business Speculation
No. Bedrooms— No. Baths � No. in Family
Garbage Disposal YES ❑ NO g- Specifications for System:
Auto Dish Washer YES NO ❑ / ��� �`
Auto Wash Machine 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 intende se change.
Improvements permit by /4 / 2
*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 1 9
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7
\aate
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ertificate of Comp etion _ �' Date —*The signing of this certificatthat the syste described above has been installed in compliance with
the standards set forth in theion, but shall in N way be taken as a guarantee that the system will function
satisfactorily for any given pe
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mockaville, NC 27028
1 . Application/Permit Requested By
Mailing Address t - B OX �-/4-1- - A ,/4C61,AMCA �' ;�?Od 4
Home Phone C1 9 7 qi Business Phone (? 9p- pl 0 /
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For : C) General Evaluation S/Tank Installation
5. System to Serve: 0 House ' Mobile Home -D/IJ 0 Business
lL] Industryu 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
Washing Machine Dishwasher Q 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: g Public Private 0 Community
9. Property Dimensions _jam 0 ,(
10. Sewage Disposal Contractor %e/ZLZL, .0fcf-y;a d ly
11 . Do you anticipate additions/expansions of the facility this system 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.
This is to certify that the information, provided is correct to thEe
best of my knowledge, and I understand I am responsible for all
charges incurred from this a cation.
Date Signa/-tr ureh
lz / o N /3A i L - f
Directions to Property : 7-
DCHD (10-89)