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P3768 Mocks Church Rd • DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c Sewa,qe.7reatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name Date✓moi �i°�c Date Location �!/�.f��i� , �� /� / .�✓ /f Fri.-�,C — ,ice �,,r i �� �,�r--tC Subdivision Name Lot No. Sec. or Block No. r. Lot Size / '-fir House Mobile Home Business _— Speculation No. Bedrooms No. Baths No. in Family -2 _ Garbage Disposal YES p NO Specifications for System: ,� n Auto Dish Washer YESNO ❑ ��` � � -) Auto Wash Machine YES �j NO E] J / Type Water Supply *This permit Void if sewage system described below is not installed within 36 months from date of issue. ( I i ,f 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 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 HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION "NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name Date N2 3769 Location 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 ❑ Specifications for System: Auto Dish Washer YES p NO fl 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. 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 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. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone Z�"/ 1. Permit Requested By ..a a';"G Business Phone 2. Address -4-n /[/G c4 70 a- 3. Property Owner if Different than Above Address fit% /UC- 02 7 a o G 4. Permit To: a) InstallIter 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 Bs IndustryOther b) Number of peopler 6. a) If house or mobile home, state size of home and number of rooms.` House Dimensions Bed Rooms 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 a2 8. a) Type water supply: Public Private Community b) Has the water supply system been approved? Yes L- fNo xEr_ 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? AllO What type? This is to certify that the information is correct to the best of my knowledge. Date Owner Signa re OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: 1457 0/ DCHD(6-82)