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z 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
� / p Permit Number
Name_( LL uCL�����.1/4y�/ 11�� Date —�`/.J �— N2 7 47
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ ____ Business -- Industry
No. Bedrooms —.No. Baths —_Z No. in Family Public Assembly Other
Garbage Disposal YES ❑ NO Specifications for Syste
Zn
Auto Dish Washer YES ❑ NO ! "
Auto Wash Ma^hine YES ❑ NO
Type Water Supply --- ��iD� ar./y'�/ or2DD,Y3•�'i� �'
*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 s• a plans or the intended use change.
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Improvements permit by _ 1
*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: q� System Installed by
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Certificate of Date
Comp letion
'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.
i
` DAVIE COUNTY HEALTH DEPARTMENT
►� IMPROVEMENTS PERMIT AND' CERTIFICATE OF COMPLETION
y Chapter 130a
.'NOTE:Issued in Compliance With Article I I of G.S.
:. SanitarySewage Systems Perm-it Number
Name r��_,�f 2 elZ1vli 17� ' s Date _�`� N2 176 4 7
Location r�/' d�.�� �YtJ �f✓ /4'� .�7 % rte•, : ,� ,
Subdivision Name Lot No., Sec. or Block No.
Lot Size House 4e!f Mobile Home— Business -- Industry
No. Bedrooms -.No. Baths —�— No. in Family Public Assembly Other
Garbage Disposal YES ❑ NO Specifications for System:
Auto Dish Washer YES ❑ NO
Auto Wash Ma^hive 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 s• a plans or the intended use change.
y
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.,
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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r
t
om
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. -
..__
i
0� DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) r
AME Ie, PHONE NUMBER
ADDRESS !(0 d �� SUBDIVISION NAME
Ix LOT#
DIRECTIONS TO SIE
DATE SYSTEM INSTALLED 3 NAME SYSTEM INSTALLED,LINDER r
TYPE FACILITY NUMBER BEDROOMSUMB RE PEOPLE SERVED
TYPE WATER SUPPLY tOVe- SPECIFY PROBLEM OCCURRING
DATE REQUESTED 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 C
Rev.1/93