190 Redland Rd .� _._. 1 �� mflf'�•�. ,.574u1 "'("d{'*I `1. d ..9K .� '/-:.1•. , t4 ��'.
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a
Sanitary Sewage Systems PermitNu >r
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Name _`Act. ����e�. Date -9 4 No 7473
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Location
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Subdivision Name Lot No. Sec. or Block No.
Lot Size " V House ' Mobile Home _T Busihess_— Industry
—
V *
No. Bedrooms 3 1lV0,4,13aths "t 2 Nb..in Family 2 — Public Assembly +_, Other
Garbage Disposal wYES p NO Specifications for Sys
y
tem:
Auto Dish Washer '-YES p NO Q- _
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.Auto Wash Ma shine YES d")No p �� /� O'
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 pla,•,gs or the intended use change.
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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.
Final Installation Diagram: System Installed by
O is ��ivos F 1 '
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Certificate of Completion Date
*The signing of this certificate shall indicatethat 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.
l~ r "= DAVIE COUNTY HEALTH DEPARTMENT ov
f- F
IMPROVEMENTS PERMIT AND CERTIFICATE--OF- COMPLETION ,
'*NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a F
s -''Sanitary Sewage Systems Pe'rmiitt Number
Name .� Date
N2
- 4 '`�2 1 4 1 3
u
Location F�'c , 1 � ��'�•�t�s a —
F
Subdivision Name / Lot No. Sec. or Block No.
Lot Size House Mobile Home _T Business __ Industry
No. Bedrooms 3 No:.Baths No. in Family — Public Assembly Other
Garbage Disposal YES ❑ NO ET Specifications for System:
T
Auto Dish Washer YES ❑ NO p' N �
YES E5, NO ❑ l `J O �( ? .; �� / 2
Auto Wash Ma shine S�z.. .
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.
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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.
Final Installation Diagram: System Installed by
� - 4
Certificate of Completion Date 1 _
*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
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAMES�� �N ��k e4 PHONE NUMBER I U
ADDRESS 1 3 Z SUBDIVISION NAME
ca � Ne LOT#
DIRECTIONS TO SITE 5 `; 6,1 � - a`c� � J
DATE SYSTEM INSTALLED 3 NAME SYSTEM INSTALLED UNDER
TYPE FACILITY aa- NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED h -94 INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge,and that I understand I am responsible for all charges Incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENTT�
Rev.1/93