324 N Pino Rdrt
bAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
NOTE: Issued.,in Compliance With Article II of G.S. Chapter 130a
Sanitary
Sewage Systems Permit Number
Name _Lr N�//�-1�.�.2/��5'c��/��y�s�'..�e" �(� a e a - N2
7769
Location
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Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _� Business _� Industry
No. Bedrooms �. No. Baths _ �— No. in Family �_ Public Assembly Other
Garbage Disposal YES 0 NO Specifications for System:
Auto Dish Washer YES ❑ NO V
Auto Wash Ma.hine YES 0 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.
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Improvements permit by. --/1/Z
*Contact a representative of the Davie County Health Department for 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. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by —
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Certificate of Completion 1 V 1 Date l q I
*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 Article 11 of G.S. Chapter 130a
Sanitary /' Sewage Systems Permit Number
Name �,rt/�,�c�/./I�rY .�+d Date17 6
N. 9
Location S-��!/< �C� ✓ G�`- Lt ! rtl0 l� r� _
Subdivision Name Lot No. Sec. orl Block No.
l Lot Size House _ Mobile Home _ Business _— Industry
No. Bedrooms ,No. Baths No. in Family_ Public Assembly Other
Garbage Disposal YES ❑ NO Specifications for Syste
Auto Dish Washer YES ❑ NO
i�
Auto Wash Ma^.hine 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.
1
-a
Improvements permit'b
*Contact a representative of the Davie County Health Department for 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. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by
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Certificate of Completion OJA Date
'The signing of this certificate shall indicate that the system described above hal been installed in compliance with
the standards set forth in the above regulation, but shall in NO way betaken as a guarantee that the system will function
satisfactorily for any given period of time.
NAM
ADD
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
ONE NUMBER ' ezS
BDIVISION NAME
LOT #
DIRECTIONS TO SITE 'Aleer
DATE SYSTEM INSTALLED SPNAME SYSTEM INSTALLED UNDER
TYPE FACILITY A/e/ye NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY a/Z6 / SPECIFY PROBLEM OCCURRING
DATE REQUESTED 149-1q- 2z% 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
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Rev. 1193