167 Quail Ridge Ln „Y
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DAVIE COUNTY HEALTH DEPARTMENT r S 0.01
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION,
*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
S nitary Sewage S
Name \Z- ystems Perm-it Number
S2 0 � CL N e 7
\, Date 3 3 d -9 N2 ! 5 0 2
Location v A
p `x
Subdivision Name Lot No. or Block No.
Lot Size 0. 0, House �— Mobile Home _ Business -- Industry
No. Bedrooms No. Baths �- No. iri Family — Public Assembly Other
,.Lr; AJ
Garbage Disposal YES (:) ,
NO ❑ ` '' Specificationsfcir.•;Syster
.,._/
Auto Dish Wash`ei Y+,ES«.p NO ❑ .: Sb . ^�3 ..1 �i. �4 e.. Cb 41
Auto Wash Ma shine ,YES W(�''NO ❑ X'
Type Water Supply _ "' . �jJ SLg9.r' ---- S a ;•�1 r� w e�Z R t v w r
*This permit Void if sew a sykem described below is not installed.within 5 years'from date of issue
This permit is subje to revocation if site plawor'the intended s ch nge.
1
Improvements permit byC� -�
*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 —
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.
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION.
{ *NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
Sit Sewage Systems Permit Number
Name—C -Q fl _ Date 3 -3 Lj N2 7502
Location �o��Cs�.�w •`°• - – `�6
Subdivision Name Lot No. e . or Block No.
Lot Size d s`a°" House 1/ Mobile Home —T Business -- Industry
N0. Bedrooms .No. Baths No. in Family -- Public Assembly Other
Garbage Disposal YES ❑ NO ❑ for Specifications System:
P
Auto Dish Washer;- YES,CE NO ❑
Auto Wash Ma^hine ,YESCp/ NO ❑`
Type Water SuPP1Y — 4D ---- S o r. �, r._ _. ct r: t✓ v f.
*This permit Void if se a system described below is not installed,within 5 years from date of issue.
This permit is subj t to revocation if site plans or'the intended use,change.
It
i
Improvements permit by
w
*Contact-a rrepresentative 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 —
x
r.
r-
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.
�J r
TDAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
" nAPPLICATION FOR IMPROVEMENT PERMIT(REPAIR) /
NAME PHONE NUMBER
ADDRESSf�.' MAIL /�/•OC',-� �� •
SUBDIVISION NAME
I-AlCksV" LOT#
DIRECTIONS TO SITE • �, d� (��A72� zl_7t
DATE SYSTEM INSTALLED • �N/AME SYSTEM INSTALLED UNDER �-
TYPE FACILITY d ash NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY_ 0e,11 SPECIFY PROBLEM OCCURRING�(�/����d
DATE REQUESTED INFORMATION In¢ INFORMATION TAKEN BY L�
This Is to certify that the information provided is correct to the best of my kno ledge,and that I un er I Tgr;c
o sible or all charurred rom this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
J 14 U
Rev.1/93