926 Duke Whitaker Rd -s
41" `� DAVIE COUNTY HEALTH DEPARTMENT
L i
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION , '
*NOTE: I'sslud� in Compliance with G.S. of North Carolina Chapter 130 Article` 13c
_ SeOge Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit, Number
/. t / •ry n P - V V
Name r „ ,,. Date
3<- � 0 �W
Location .' /
Subdivision Name Lot No. Sec. or Block No.
Lot Size House '�� Mobile Home — Business Speculation
No. Bedrooms No. Baths — '-1 No. in Family _—
Garbage Disposal YES p NO pi Specifications for System: `
Auto Dish Washer YES Ep NO p r r'
Auto Wash Machine YES [ NO
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of-issue.
i
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 �rr-yC
� 1
Certificate of CompletionYom - ,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.
M /
29� 7
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Departmentfo 4
0t ' +
/
Environmental Health Section /11�
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN
/ISSUED.
/ -T Home Phone
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1. Permit Requested By 'aY / d maR, Wi1i I T Q /�P✓ Business Phone
2. Address 86X IS-3 - oc Seo ale A• L'. ,27a2�
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House ✓ Mobile Home Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions �e/�(Vg
Bed Rooms_Bath Rooms Den w/Closet—L—
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 •2 urinals garbage disposal
lavatory showers washing machine j
dishwasher sinks 3
8. a) Type water supply: Public Private Community_ Z
b) Has the water supply system been approved? Yes No—
9.
/
9. a) Property Dimensions 16 - d 1 "y a37,/` 5� Z ,
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?
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
pl lo 1,44 efy ex, /14l 744W 7ip ,rem
70 A✓00cl-r
DCHD(6.82)