135 Rupard Trail (3) _ ,Rr DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION G ;
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c �S
Sewage Treatment and D' posal Rules (10 NCAC 10A .1934-.1968) , Permit Number y.�.
J
Name yc,e Date376 7
Location
Subdivision Name Lot No. Sec. or Block No.
Lot SizeHouse Mobile Home Business Speculation
No. Bedrooms Q No. Baths _ _ No. in Family _
Garbage Disposal YES ❑ NO M--` Specifications for stem:
Auto Dish Washer YES ❑ NO 9-11, fp p a ,
Auto Wash Machine YES [; NO -❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
V v \
fi
Improvements permit
*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 -
rPl�
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.
-,_ '�- ► APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
V Davie County Health Department Z
00
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone e7- 9g-
1. Permit Requested By Business Phone
2. Address J�PE7 `An k 6 d ,Wee -v;//4 4 C Z 70 2
3. Property Owner if Different than Above
Address
4. Permit To: a) Installer Alter Repair
b) Privy Conventional-jZOther Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Bs
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
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) d
7. Number and type of water-using fixtures:
commodes urinals garbage disposal
r )� lavatory showersy washing machine
dishwasher sinks
8. a) Type water supply: Public Private_ Community
b) Has the water supply system been approved? Yes Not/
9. a) Property Dimensions Z
b) Land area designated to building site
c) Sewage Disposal Contractor <'e 4�
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? iz0
What type?
This is to certify that the information iscorrectto the best
^oof my knowledge.
Date Owner gignature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
At r
Directions to pro erty:
DCHD(6.82)