1360 Country Home Rd `0 DAVIE COUNTY HEALTH DEPARTMENT
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r IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
r / � Permit Number
Name ' �' - / /� /—� Date --'7 /'i�!� / .� L?r� �!
Location ` ►�r�z�,u I'.�., �. - ,,:1 �,J ��� �� : r� CN.—
SubdivisionName 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 ❑ NO .0'
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.
i
Improvements permit by r
*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
1
72L,
Certificate of Completion ` ` �~`L "t Date
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*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 COUFTY HEALTH DEPARTiIEITT
ENVIROIHMEBTAL HEALTH SECTION
SOIL/SITE EVALUATIOIT
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VATS �t�� DATE
ADDRESS
�p � �/o LOCATIOt1
LOT SIZE /
TOPOGRAPHY: r �o
SOIL TE�,TURE o
,e
SOIL STRUCLU E e
DEPTH:
RESTRICTIVE HORIZONS: ?"L,/,Oxv
PERCOLATION FATE: Presoak Mark & time I Drop Time Rate/ lin. Inch
2. z 'y x3. <
***CLASSIFICATIOIT s
Suitable (::P:rovisionai`lySu`itab1e Unsuitable
COMHEUTS
SAID?ITARIAIT
SITE DIAGF"
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
PO Box 848/210 Hospital Street
Mocksville,NC 27028
Phone: (336)751-8760
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
"(Check One) REPLACEMENT❑ REMODELING ❑ RECONNECTION ❑
Name:
�,1�/G�� �%G,fl,d �� Phone Number: '� / 3 �' (Home)
Mailing Address-/!�"D� �irir`y ��ri9G' �ci�• `- s' (Work)
Detailed Directions To Site:
Property Address: I L�fT�-�: %% lAle--
Please Fill In The Following Information About The Existing Dwelling.
Name System Installed Under: R��C�''/ '�E-� /tfi�'f�G�-s Type Of Dwelling:_ .��5'F
Date System Installed(Month/Day/Year):" S Number Of Bedrooms.__ ' Number Of People: �---
Is The Dwelling Currently Vacant? Yes❑ No,;e' If Yes,For How Long?
Any Known Problems?Yes❑ NW, If Yes,Explain:
L..Please Fill In The Following Information About The New Dwelling:
30XS6
Type Of Dwelling: Sri G .�' Number Of Bedrooms: /_ 7 Number Of People:
Requested By--,/ i ,► ---R!` Date Requested f�—
(Signature)
For Environmental Health Office Use Only
Approved Disa roved ❑
PP PP
Comments:
Environmental Health Specialist Date
*The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a
guarantee(extended or limited)that the on-site wastewater system will function properly for any given period of time.
Payment: Cash❑ Check❑ Money Order❑ # Amount: $ Date:
Paid'By: Received By:
Account;#: Invoice #: