454 Sain Rd ^
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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
^NOTE: Issued in Compliance with G.G. of North Carolina Chapter 130 Article 13c '
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name j Date N2 6 1-
53 3
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Location �
. Subdivision Name
—='—' --- Lot No. Sec. or Block No.
Lot Size House Mobile Home -_-_-_-_ Business -_-_----- Speculation --_-_-_-_
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No. Bedrooms_--�����_ No. Baths No. in Famik/Garbage __���_--
Disposal^ , YES C] NC} �g- '
Auto Dish Washer YES ffg^'
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Auto Wash Machine YES []` NO {r�� �
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Tvoa Water Supply
*This pannd Void if sewage system described below' is not installe ?within 36 months from dote of issue.
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Improvements permit bv
*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 complKtion. Telephone Number: 704-634-5985.
Final ' 411 System Installed by
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Certificate ofCompletion Date Cl
*The signing of this certificate ohmU 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 systemvviUfunction
satisfactorily for any given period of time.
. `
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
"NATE: 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 " -�� �� ��.�i t%`, ry �', Date �� - `-1 - ri''t N '�
- -
Location .. t � � ^a� a
«Subdivision Name Lot No. Sec. or Block No.
Lot Size _ :'D)G House Mobile Home _ Business Speculation
No. Bedrooms No. Baths No. in Family _
Garbage Disposal YES ❑ NO p' Specifications for System: N:� -
Auto Dish Washer YES ❑ NO 0,"
Auto Wash Machine YES ❑ NO [P/ o v� y �, ' x
Type Water Supply : . �.. � _
*This permit Void if sewage system described below is not i stalled within 36 months from date of issue.
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 comp) tion. Telephone Number: 704-634-5985.
Final Installation Diagram: l�pl' System Installed by �',��a�� �� 4t-
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Certificate of Completion' \ �•°�- �- � _ J
Date n
*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.
INFORMATION FOR SEPTIC SYSTEM REPAIR PERMIT
NAME PHONE NUMBER
ADDRESS ��( ck SUBDIVISION NAME
SUBDIVISION LOT #
DIRECTIONS TO SITE
DATE SEPTIC SYSTEM INSTALLED
NAME SEPTIC SYSTEM ORIGINALLY INSTALLED UNDER
SPECIFY PROBLEMS THAT ARE.-OCCURRING AC)�' `N