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�...� DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND .CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
Sanitary Sewage Systems G Permit Number
Name— N v R�U N Date�_ " / N2 6 619
Location t 5 o c
Subdivision Name Lot No. Sec. or Block No.
Lot Size 3 House Mobile Home Business __ Speculation
No. Bedrooms No.'Baths No. in Family f
Garbage Disposal YES E) NO E]r Specifications for S stem:.
Auto Dish Washer: YES ❑ NO [I p y
Auto Wash Ma shine " YES NO ❑
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.
L
S '
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 �—
Q
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2
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.
.. - DAVIE COUNTY HE141TH-"DEPARTMENT
IMPROVEMENTS PERMIT AND .CERTIFICATE OF COMPLETION
�- *NOTE`Issued in Compliance,With Article II of G.S.Chapter 130a
j Sinitary Sewage Systems _ PerrOlt Number
f Name Date - j 1 ND
6619
Location 1 .1 >..� �. �� o �� < y-, W� V) .
_ \ \ _� `'fit�'. ...J•;;.1�, 1-1.. ✓*'�u'_h� 1 r•!�v,..
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home —� Business Speculation
No. Bedrooms r� No. Baths ' No. in Family _
Garbage Disposal YES ❑ NO E f Specifications for System: _
Auto Dish Washer YES ❑ NO p'
Auto Wash Ma:hive YES NO ❑
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. ,
r
E.
3-
w
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 byqu
w
F
L
1
Certificate of Completion Date --) 1 72
*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 shalin NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time. .. .. -
y ~ ' INFORMATION FOR SEPTIC SYSTEM^REP.AI-R PERMIT
NAME �`� PHONE NUMBER
ADDRESS SUBDIVISION NAME
SUBDIVISI'O`N LOT #
DIRECTIONS TO SITE \�' ON,-
QLoa
DATE SEPTIC SYSTEM INSTALLED
NAME SEPTIC SYSTEM ORIGINALLY INSTALLED UNDER
SPECIFY PROBLEMS THAT ARE OCCURRING
DATE REQUESTED �, - - q� INFORMATION TAKEN BY