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DAVIE COUNTY HEALTH DEPARTMENT Ioqy{�-1>
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ok
*NOTE:Issued in Compliance With A aioejl(�of 9s{C�hgpierA�ba
�nitary.Sewa a Systems r/ cf� � � Permits 6l�elr
mm, e u��.aIle r� �"-k"/y7�✓ G
Name Date Q NO
Irk
Location —
Subdivision Name Lot No. Sec. or Block No.
Lot Size House — Mobile Home —.q_ Business _— Speculation
No. Bedrooms .No. Baths ! No. in Family v� _
Garbage Disposal YESNO ElS� ificati n �for System:
Auto Dish Washer YES NO El
Auto Wash Machine YES 4N�OG❑ ��'l.`O�!'SX/� "A*
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.
F
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
/601
Fu �N
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F-
0 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.
j APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
Application/Permit Requested By�_e M M i e� i 1 91- �/ Z �?u Y Yle44,
Mailing Address P—'� 6A R ok 1,5(J 0 d Il R-AIC e, ,ue a 70 U „
,/ e Home Phone 9� -���� Business Phone �9/!21 va ve- r2vam�
2. Name on Permit if Different than Above
1 3. Application/Permit for: ❑ General Evaluation 2r septic 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 ❑ Basement/No Plumbing
rANo. of Bedrooms 3 ❑ Washing Machine
&,�No. of Bathrooms 12? ❑ 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: p Public ❑ Private ❑ Community
8. Property Dimensions S-14cf Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes "o
If yes, what type?
'NOTE: 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:
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j USf �e°loo zti Yred art -1� dousoA) kt Shin ad. i S
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This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurrrd from this application.
�q 9.:2 L
DATE SIGNATURE
CONSENT FOR SITE EVAL ATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: 1. I OWN the property. ❑ 2. I 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 representative of the Davie County Health Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
\DCHD(12-90)