399 Pine Ridge Rd iTTii 65tFT'i"v+ti�wi'F'w7'.ac,�,...iw•P.njy�,,,.,y�i+`5 W'�>`"�'W-F��'' 'TY6`�Y,y'rgv"'$,w.aa.w'-w#"liav'radar'•�n`f.»'sr+w:+:,�,y-t,ryr"r`?1`a*i.Ya✓sw:.r�"^.,+.w'tr""tay..3o'a avt"''�,w"v.'.,"'�y.;r.n'nr`...i+r"�,•tyetij+F S"=*�iY�
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a
Sanitary S wage Systems Permit Number
Name Gr/'a� /4 Date N2 7137
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business _— Speculation
No. Bedrooms 3 ..No. Baths `� No. in Family_
Garbage Disposal -YES p NO Specifications forS stem:
Auto Dish Washer' YES NO p c��X �ir
Auto Wash Ma:hive YES j 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 siteplans or the intended use change.
Nmid
y
Ga
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
l�
Certificate of Completion """L _ 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.� ���' Tl �.;r�,'}� .-4 ,-e.'`� } 4•aa Jt k+t�'.ayr.5 r„ s�.,,, f. •a . .r •. .. ...: ` , :Fa :' 3:; t' _
DAVIE COUNTY HEALTH DEPARTMENT
.� IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
- Sanitary Sewer a Systems I Permit.Number
.r
/ . ` .� No_ 713 7 .
Name C'' ,�d� ..... Date
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size —� House Mobile Home _T Business __ Speculation
No. Bedrooms No. Baths a No. in Family y _
Garbage Disposal YES ❑ NO 1S Specific tion for�S Stem:
Auto Dish Washer YES NO ❑ �; "'G% / r"y
Auto Wash Ma thine YES [ NO ❑ 't
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
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.
b Installed stem
Final Installation Diagram: System y
• r
f=
i.
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.
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DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION i
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) I
NAME PHONE NUMBER 2)-S
ADDRESS �Z�C eN y\oc�S. SUBDIVISION NAME
LOT#
DIRECTIONS TO SITE O S \ R
DATE SYSTEM INSTALLED �1 W NAME SYSTEM INSTALLED UNDER
TYPE FACILITY C,"� NUMBER BEDROOMS 3 NUMBER PEOPLE SERVED Lt
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING C_"jet - -�
DATE REQUESTEINFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge,e7nt I understand Irresponsible for all charges Incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENTLX
Rev.1/93
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