2416 Milling Rd (2) _ j 0
DAVIE COUNTY HEALTH DEPARTMENT
•-'.L` ` ' IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems Permit I Number
Name -a f1,!�.j `� � /� ,li% - f Dates N2 71920
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Location
✓1" / ani� // � / �'._�__�_�r!`', v/i /. f r
Subdivision Name Lot No. Sec. or Block No.
Lot Size ''`{ House Mobile Home __ Business __ Industry
No. Bedrooms '` ..No. BathsNo. in Family__ Public Assembly Other
Garbage Disposal YES ❑ NO p' ` Specifications for System:
Auto Dish Washer YES [p NO ❑
Auto Wash Ma^hine YES p NO ❑ �C y "x/.
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
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM. /
1
r
I
ri
Imp ovements permit by
*Contact a representative of the Davie County Health Departmen fo final inspection of this system between 8:30-9:30 A.M.,
1:00.1:30 P.M.or 4:30-5:00 P.M.on day of completion.Telephon umber: 704-634-5985. /60
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Final Installation Diagram: (y� ys m I st lied by
1 - r
Certificate of Completion L` / 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.
�k APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER I �QVED
Davie County Health Department
Environmental Health Section JAPJ 2 3 U95
P. O. Box 665
Mocksville, NC 27028 «------ -
J-
1 Application/Permit Requested By L
Mailing Address -,AwrI;nl -RD Home Phone i«
' Q"--7 q Business Phone�'!9 g-�&-y
2. Name on Permit if Different than Above
3. Application for: ❑General Evaluation 4Septic Tank Installation Permit
4. System to Serve: .'House ❑ 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 -p-Washing Machine
No. of Bathrooms e—" 147-1 ? 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 Showers Water Usage Figures
7. Type of water supply: Public ❑ Private ❑ Community
8. Property Dimensions A 02c� Sewage Disposal Contractor LBS
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes P-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.
Directions to Property:
This is to certify that the information provided is correct to the bes my kn ledge, and I understand I a esponsible for all charges
incurred from this ap lication.
DA E ATUR
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: K. I OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be co leted y the owner or perso authorized by the owner:
I hereby give consent to the authorized representative a ounty Hea ent to enter upon above described
property located in Davie County and owned by
to conduct all testing proced res as necessary t determine said site's i ity or a ground absorption sew ge treatment
and disposal system
`L �
DATE SIGNATURE
DCHD(1/93)
f i
{, APPLICATION FOR SITE EVALUATION/IMpROVEMENTS PERMIT
dDavie County Health Department
Environmental Health Section
U Q P. O. Box 665
I l Mocksville, NC 27028
�'
�
1. Application/Permit Na nested By
Mailing Address • ��
Home Phone ,. usiness Phone
2. Name on Permit if Different than Above
3. Application/Permit for: QT General Evaluation O Septic Tank Installation
4. System to Serve: ED House ❑ Mobile Home O Place of Public Assembly
O Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
O Basement/Plumbing
No. of People O Basement/No Plumbing
No. of Bedrooms O Washing Machine
No. of Bathrooms ❑ Dishwasher
Dwelling Dimensions O Garbage Disposal
6. If business, Industry, place of public assembly, other: Specify type ►"I^14
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No.of Showers Water Usage Figures
7. Type of water supply: ❑ Public ❑ Private ❑ Community
8. Property Dimensions Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is Intended to serve? O 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.
Directions to Property:
This is to certify that the info mation provided is correct to the�gest of my knowle ge, and I understand I am responsible for all charges
Incurred from thi appi' ati the,
DATt SIGNATU E
CONSEN FSH BilE EVALUATION M JOE PD-NE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. (C 2. 1 DO NOT OWN the property.
If you checked 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 he Davie Co my Healt pepartment to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to getermine said site's suitability for a grown absorption sewage treatment
and disposal system.
DATE ATURE
DCHD(12.90) .'t.