633 Ratledge Rd (2) 4 DAVIE COUNTY HEALTH DEPARTMENT
• ''" _ IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
Name stli� /U,/d � /s ; l/;;=r r Date
Location - -t— Y�1` Z-2 J,r
Subdivision Name Lot No. Sec. or Block No.
Lot Size — — House — ✓ Mobile Home _--_ Business -- Industry
No. Bedrooms No. Baths No. in Family Q__ Public Assembly Other
Garbage Disposal YES NO p Specifications for System:
Auto Dish Washer YES NO p "y
Auto Wash Ma^hine YES NO []
Type Water Supply _—._ G�✓/l/ ----- --- �sG'� ,E � � J
'This permit Void if sewage syst described below is not installed within 5 years from date of issue.
This permit is subject to revoca i n if site plans or the intended use change
ATTENTION: YOUR SEPTIC SY EM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM.
/V f/6 e
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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.,
1:00.1:30 P.M. or 4:30-5:00 P.M.on day of completion.Telephone Number: 704-634.5985. 4
Final Installation Diagram: System Installed byyrc �
�jt0`
_ 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.
AA
` APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section 4/ 11
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By �� AL. L �� vi A/
Mailing Address Z -=J'/'t- d-r- e-J- Home Phone(-7G`t�)
�'Lt oo?L¢.�'d�``/� �✓�' f Z /
/J""' Business Phone 2 663—a',��
2. Name on Permit if Different than Above "-
3. Application for: ❑General Evaluation eSeptic Tank Installation Permit
4. System to Serve: House p'Cvlobile Home ❑ Place of Public Assembly
Business ❑ Industry J ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision �/ Sectiones Lot #
C�7 BasemenUPlumbing
No. of People ❑❑�Basement/No Plumbing
No. of Bedrooms 3 Er"Washing Machine
No. of Bathrooms 3 93/Dishwasher
Dwelling Dimensions �S �� ` r Er-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 Watters Usage Figures
7. Type of water supply: El Public El Private ❑ Community
8. Property Dimensions > 3 AcX-ea Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes EKNo
If yes, what type? Al
'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:
�� , ���s•-t. ����o� r2o t� �r� osJ deo -7--,*�1
v
Cvze�/C C �n�� . —700 2�
_,2-,-,z-/<. dam,,e-
l�o�s�C ws�' . rzu,'o 1�1'/ 0c.."AQC,0( J'464;�-, 0 2
.�v u •oma � ox� o � ��3z
This is to certify that the information provided(s correct to the best of my knowledge, and I understand I am responsible for all charges
incurred from thisplicat'on.
/2a Gl.
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: 1 OWN the property. ❑ 2. 1 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 the Davie County Health Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
DCHD(1 193)