214 McClamrock Rd A DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With �
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�`'' � Perml umger
Sanitary Sewage Systems rr
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Date N2
Name
Location.
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _f. Business __ Speculation
No. Bedrooms .No. Baths No. in Family _
Garbage Disposal YES ❑ NO
Auto Dish Washer YES Spgc'fications for System:
Auto Wash Ma thine 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.
Improvements permit.by _rya
*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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1�4j Certificate ofcompletion Date
"The signing of this certificate sha I indicate that the sstem 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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Appiipation/Permit Re uested B E2AJJ& -
Mailing Address 4 C7 r, -7 7 ae 6 Home Phoge
Business Phone i
2. Name on Permit if Different than Above ����
3. Application for. ❑General Evaluation rSeptic Tank Installation Permit
4. System to Serve: ouse ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot#
❑ Basement/Plumbing
No.of People ❑ Basement/No Plumbing'
No.of Bedrooms `3 Washing Machine
No.of Bathrooms ❑ Dishwasher
Dwelling Dimensions ❑ Garbage Disposal
6. If business, industry, place of public assembly, 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 Shower$. Water Usage Figures
7. Type of water supply: R 1.Tu'b-11c ❑ Private ❑ Community
8. Property Dimensions Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No
If yes,what type?
'NOTA; 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.
Directigns to Property:
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.
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.
9-
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DATE SIGNATURE
CONSEN OR SITE EVALUATION IQ RE DONE 9N ABOVE DESCRIBED PROPERTY
MAST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you chacked Box#2,the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
WHO(1/93)