144 McCullough Rd""t'k%r•. ra.it::vaS,F:.�Sry+i�,sar.�.Wri'yir".ss+.li:-+.•.yiti. �°Wfn"."'_Y�ira.,.ba�.,,;l,:x„_,..:.,+�+....-�--rq.....,,,,....:-�.y--�-r•.Rw-...svtw��.�-a: � •�.1'v.'rf rte.rcLf!`"4ti..+x
' DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a
S9 �itary Sewage se'Pstems g �`� Permit Number
" -
ame � - � St VA QY Date N2 72.96
Locationv c� 0 C-\&S D
06 1
Subdivision,,Name Lot No. Sec. or Block No.
Lot SizeX� °+� House, Mobile Home Business Speculation
No. Bedrooms `` ' No.,Baths No. in Family
Garbage Disposal YES' j �NO ,;,u y Specifications for System: °
Auto Dish Washer' YES,❑. NO,,[] �`
Auto Wash Ma.hine` .,;.—YES ,❑ -,NO ❑
Type Water Supply„ ---
y
*This permit Void if sewag6 system described below isnot installed within 5 year's from date of issue.
This,permit is subject tovreyocation if site tans or the intended J echange. -
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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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Certificate of Completion Date �-3 -9 3
*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. ,
- -. DAVIE COUNTY HEALTH DEPARTMENT ' R
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
anitary Sewage Sysem _ zj j Perm!#.,yug�b�er
Name� S��4.Y Date NO r
--��"
Location
C: / ♦• c^s� `�ti` (�v\�\ civ til. �`' 1. sa `SV ' t=
.'."'..^- ............
�
Subdivision,Name Lot No. Sec. or Block No.
-r (Ylr�t ;
Lot Size House Mobile Home Business Speculation
No. Bedrooms � - .No. Baths ! No. in Family ~I _
Garbage Disposal YES C3-:- Specifications for System:
Auto Dish Washer YES ❑ NO ❑ e,o Sr
Auto Wash Ma:hive YES E], NO E],
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 the_iatended-�,s�c ange.
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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 ""`� �`� - T
c
-j"a�;t� - (2.a,,.9 � •k-�� nPP"I . 3.4-sP""•
C�q Z-` V'ra'-
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.
#
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME PHONE NUMBER
ADDRESS 74k. ,�L ��. SUBDIVISION NAME ' b°
LOT #
�► DIRECTIONS TO SITE71
]MOKA he"w_ -:57
G�� �7.ILLDZIG�II �d. OCI,SG� dh..
DATE SYSTEM INSTALLED PS'KVAME SYSTEM INSTALLED UNDER Gi'/L' �1/
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY I�)fh SPECIFY PROBLEM OCCURRING &7n7ndVdr't_ does-
DATE REQUESTED _5 INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge,and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1193