300 Pudding Ridge Rd is i l
DAVIE COUNTY HEALTH DEPARTMENT �U6 Dizi
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968)'"' Permit Number
Name Date 3941
Location _`" �L' j( `• �. /f
Subdivision Name Lot No. - Sec. or Block No.
Lot Size '`' House �-- i" obile Home _ Business Speculation
No. Bedrooms No. Baths No. in Family -l
Garbage Disposal YES ❑ NO [3-- Specifications for System:
Auto Dish Washer YES ❑ NO ❑ i
Auto Wash Machine YES ❑) NO -❑ yi '
Type Water Supply _—
'This permit Void if sewage system des ribied below is not installed within 36 months from date of issue.
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.
Final Installation Diagram: System Installed by
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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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone "?Z(2 F'So
1. Permit Requested Ely-
�L // v`s Business Phone 773 3/SL�
2. Address J Bwe _� C n.r ,G, 2 -70/L
3. Property Owner if Different than Above /W/'S
Address �uv`)d w aG l P;/9P C8
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: Housed Mobile Home Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions / "f
Bed Rooms Bath Rooms � Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes 0_1 urinals ll garbage disposal 0
lavatory showers washing machine
dishwasher sinks 91
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 06 / 11,90
b) Land area designated to building site ACrAA
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? f
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS f-vye-
Allow 5 days for processing
Directions to property:
-713
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DCHD(6-82)