881 Sheffield Rd DAVIE COUNTY HEALTH DEPARTMENT
r . -IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'NOTEAssued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage SystemsNum
rmit ber
Pe
Name �iJ=j ;;�/l�� `/r. �i f ', � i Date. y �� ` ', NO U
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size- —'-LLC House Mobile Home _ Business Speculation
No. Bedrooms No. Baths 5r No. in Family _
Garbage Disposal YES ❑ 0 p''
Auto Dish Washer YES NO p Specifications for System:
Auto Wash Ma.hive YES f NO ❑ ,; ;i ;
.� ;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.
Improvements permit by. -
*Contact a representative of the Davie County Health Dep rt nt f
in inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Tele ho umbP 704-634-5985.
Final Installation Diagram: System Installed by �PiLM�✓i�, ��
r�
Certificate of Completion � cafe
*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.
DAVIE COUNTY.,HlI �:
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT (�
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1 Application/Permit Reques By Q��a A
Mailing Address70
Home Phone 71,1--7 p Business Phone
2. Name on Permit if Different than Above
3. Application/Permit for: ❑ General Evaluation C9--b`eptic Tank Installation
4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot#
❑ Basement/Plumbing
No. of People R ❑ Basement/No Plumbing
No. of Bedrooms 2oWashing Machine
No. of Bathrooms ["Dishwasher
Dwelling Dimensions ❑ 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 Water Usage Figures
7. Type of water supply: 0-43,ublic ❑ Private ❑ Community
8. Property Dimensions cC'-e- Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes R-No
If yes, what type?
KOTE: 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: 9c, dctJ 1, K/e4 6Q
� Y
This is to certify that the information provided is correct to est of nge and I understand I am responsible for all charges
incurred from this application.
f—C- _
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: V1. I 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 representati f the unty Health Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to term id site's itability r ground absorption sewage treatment
and disposal system. n
DATE SIGNATURE
DCHD(12-90)