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180 Joe Myers Rd ! DAVIE COUNTY HEALTH DEPARTMENT f 1� IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION "NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c Sewage Tread ent and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name / — Dateel Locatio Subdivision Name Lot No. - Sec. or Block No. Lot Size House Mobile Home _ Business Speculation No. Bedrooms _ No. Baths No. in Family _ Garbage Disposal YES ❑ NO E?--' Specifications for System: Auto Dish Washer YES NO ❑ �� ; e Auto Wash Machine YES T NO -❑ .: Type Water Supply *This permit Void if sewage system described below is not installed within 36 months from date of issue. r�) /j P.411) 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 r� <7;11` 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. i4 Y� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section � P. O. Box 665 dd Mocksville, N.C. 27028 JUL Z Q '�p�n l N HA_LL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone QYZ7Z3� 1. Permit Reques d By e2- 2066 2. Address 3. Property Owner if Different than Above Sit vrr e Address 4. Permit To: a) Install Alter Repair b) Privy Conventional ✓Other Type Ground Absorption c) Sub-Division Se Lot No. � 5. System used to serve what type facility: HOUSeMobile Home Business— Industry— Industry Other b) Number of people 2, 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions Bed Roomsav_z 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 /� urinals garbage disposal lavatory ! showers washing machine dishwasher sinks 8. a) Type water supply: Public Private Community b) Has the water supply system been approved? Yes No 9. a) Property Dimensions b) Land area designated to building site c) Sewage Disposal Contractor 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? AID What type? This is to certify that the information is correct to the best of my knowledge. ,7_ Zo rsr7 R"'�K e, �W' Date j owner' SgKature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: 7c? /�e, L� © -� or ;o c-A-S U i LLP, e e W - o s Y-o C©r2 Nq�ze K RGp ffcr ne7�La h-f- �U Q%x-/ �a c R �h R.R �Ra �s a u� N L4s-�- .f7 Ri v-e--- D lea e S r'DLa��- 6�L�w Dow&f RR , douse- L� t�ti BLue, DCHD(6-82)