P8077 Peoples Creek Rd Ty5... '.. -N _:=.: y .yr-,e .• ..e..�«-s.� ;.."t -..:' , :t , 4.r- a ... .- +n y.. v s .. _.-.- - v .r,_- - Y .. . -...t r.. :-'
DAVIE COUNTY HEALTH DEPARTMENT
4' IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issuild in Compliance With Article II of G.S.Chapter 130a
-Sanitary Sewage Systems ?7coG Permit Number
Name ol'-lef: �i�4 --- Date N2 8077
Location _�' �
f
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 p NO p' Specifications for System:
Auto Dish Washer YES NO Q\, ✓ �%-r<✓
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
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM.
1�
Improvements permit by — rll
*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
1
.000
Certificate of Completion Lt / __Date _
'The signing of this certificate shall indicate that the system described above has been installed in 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.
j •
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER
Davie County Health Department V �! ! 9 ,
Environmental Health Section r
-995
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By D I C-V, V no 1 e-(-.
Mailing Address P D . Ecy 07 o L 3 Home Phone a 3
Ad v o-nce., N)c a-,7(D0& Business Phone ,A
2. Name on Permit if Different than Above M IA
3. Application for: ❑General Evaluation @19'eptic Tank Installation Permit
4. System to Serve: Clouse ❑ 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 B'Washing Machine
No. of Bathrooms 1. "ishwasher
Dwelling Dimensions 31 58 ❑ 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: R "Public ❑ Private ❑ Community
/S7)( a 9 9)( 17& -i 61 f� (l it�� ``'IA
8. Property Dimensions Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes o
If yes, what type? N
'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:
I- 40 E io VAWJ 8DI
Bol S 4o Peeples Crecy- 'Rd (ncy-4- +0 AcIVance Floest � �h eichcl's bczl`en,.�
-Pro per4- 1 o ea I ed approxi rn0_: C j o-�' a m i I e. on +-h e- I e-�-+ .l
L a+ -Fb be +c-s-�ed , V)as Cz v i s iI e we- I I
This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurred from this application. _
DATE /r NA t:iT RE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. V2. I 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 th�Davie County alth Department to enter upon above described
property located in Davie County and owned by /�",-A/1L( O zo-, B�t�
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
9S-
DATE SIGNATURE
DCHD(1193)
`iJ' 1 r •, l
t Vey, r�
----------------------------------------------------------------------------------------------
r
/29/94 02:50 WADE H. LEONARD, M ATTORNEY P,01
I. C Ray Cotes rurllfy that on__.. April 14 1p 83 1 aurvr�rd the property shnwn fill thin plat:
�t Ihn prolwHy lints 'and lnratlon of •mill slrurtures nre aerurjtrl� fli.):vn hereon: flint no gtnxture laratefl on /hitt property
v�t;irlu'� nn r,n� :0.1aerni .ttreet w p:upnity; t+nrl flint no mrurture on a<lincent properly enrronehr: on file premises
+eyed, DIVISION NOV. 25, 1994
00. _
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