1367 Sheffield Rd _ ,. ., ^^.y-�s�..+ csw'.«Y+-"�`--o...-+4-.�-..._.z-..»...s..i-.n;,•c=P'"� xti'r"tp.y'.""'"""'-'.'.'`_, :.-.y'-.s,.-•ov--«�a.:-.-a..w--.:...roti+cc,+}.-...-.-..-.t,,,.d.�...,-+:.f,�T-,....,,r...�.w-
$� DAVIE COUNTY HEALTH DEPARTMENT 3 3 v
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
.*NOTE:Iss6ed iii Compliance With Article I I of G.S.Chapter 130a
Sanitary Sewage systems Permit Number
Name �-�''�s Date a a�' q 3 N2 70.42
Location
1 �_3 O 0 \�5 t\\ N �
Subdivision Name - - Lot No. Sec. or Block No.
Lot SizeHouse Mobile Home _T Business.
speculation
No. Bedrooms ,No. Baths No..in Family _
GarbageDisposal YES p NO [2/ W
Specifications for System: _
Auto Dish Washer. r YES ❑` fVO. [
Auto Wash Ma shine C--YES4(B NO ❑ �. x�_ sUs-
Type Water Supply."
*This permit Void if sewage`system*described below is not installed within 5 years from date of issue. t�
This permit is subject to revocation if site plans or-1he intended use change "a
13,J
IrrtproVements 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 completion. Telephone Number 704-634-5985.
IZZ
Final Installation,Diagram: - 'Systern Installed by
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Ce 'ficate of Completion _ Date 3 - 93
•The signing of this certificate shall indicate tha escri d r installed in compliance with
the standards set forth in the above regulation, but shall in` 0 way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
'.' r _ r�lr" . .'j'1 ,.'Y;<+ '.vfi"'.,1.. '•.�•r j"`'4T`a;.r . ,.i: � ... _.. �. _. .. r 'i. •"` •;'.
DAVIE COUNTY HEALTH DEPARTMENT '•3 o
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
Sanitary Sewage Systems Perms u or
Na �,a� �'.L �.�5�. ,.� ;�r- Date - j p �}
me ' -
N
Location �'� � �.� �`,+� � � r •��o���� u ��� �. , ��-� '� . �.'� ��.z:
Subdivision Name �-"" r Lot No. Sec. or Block No.
Lot Size �, ` House Mobile Home�T Business -- Speculation
No. Bedrooms ''rNo.'Baths No. in Family —
'
Garbage Disposal YES-d NO Specifications for System:
Auto Dish Washer YES ❑ NO ['f
Auto Wash Ma shine -YES Ef NO C]
--
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.
'A
-- 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 completion. Telephone Number 704-634-5985.
Final Installation Diagram: System Installed by
v
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014
11GI
Evi_
N
p Ce 'ficate of Completion ' ' Date -'
'The signing of this certificate shall indicate thai ie sys er(i describe Love-ha-bei installed in compliance with
the standards set forth in the above regulation, but shall in 0 way be taken as a guarantee that the system will function
satisfactorily for any given period of time. _-•,3 �`' '" 4 � ��,
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) 1 '
NAME PHONE NUMBER
ADDRESS �� \ \,�`L \ SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE Co Li W \\ cs-,
DATE SYSTEM INSTALLED 9 NAME SYSTEM INSTALLED UNDER
TYPE FACILITY `\b0s---- NUMBER BEDROOMS 2k NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED �-" 13 INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge,and that I understan responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
L00JAV712 4 —
Rev.1(93