326 Shutt Rd e�lr'�d• '(+ '/ 'wy x ne'r«3;^�s:C'.f[=wsi�::r:�s1'+°kY.!s1�. ...-rte .jr""'�' xa..s,,F.-,5'ptj:.."`_,y. ,. z_-»�,:t; .r-�'a_ qz. ,�' '�.i.'_ "�,..t. svri"-y{'t' a••q.};s
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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
�gitary Sewage$ystemg _ Permit Number
ae� �. �R X00 � � 3 �� No 6876
Name Date
LocationOTT
Subdivision Name �t"'' "� Lot No. Sec. or Block No. " l
Lot Size I'`House:,, A'Mopile Nome � Business — Speculation
No. Bedrooms No. Baths No. in,Family
s
Garbage Disposal YES p NO''> "`
Specifications 4or.System:
Auto Dish Washer YES ❑ NO ❑ n ► ' y I 1
Auto Wash Ma.hine YES;,❑`_NO ❑ 'L
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.
44 c .
F r 1
F ,
Improvements permit by
'Contact a representative of fie„D vie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. o of completion. Telephone Number 704-634-5985.
Final Installation Diagram: System Installed by –
f t
P�r. "
p �,v
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.
w�.i �j .v y::'y.,�:a�r.,., � ,.�:..'S ` ".•�.,x,n "] '�-�z .n-:+„� .fM-_���Ya.t ..� w1-"i:` ro - ,-
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ) j; C
*NOTE:`Issued in Compliance Wlth Article 11 of O.S.Chapter 130a
S�eniIt ry,Sewage 4�ysterfr`s� �, . 3 . `�1� Permit Nu4er
Name \ \ ” 'Date No 6EN.
�v
Locatl
i
Subdivision Name Lot No. Sec, or Block No.
Lot Size '' House Mobile Home ,._: Business __ Speculation
No, Bedrooms `J ,No. Baths No, in Family..--
Garbage
amily.. _Garbage Disposal YES ❑ NO,❑ Specifications"for System:
Auto Dish Washer YES ❑ NO ❑ ,��
1 i"'
Auto Wash Ma:hine YES.-❑ NO M _
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,
IV I
v
Improvements permit by
*Contact.a representative d4he,D vle County Health Department for final Inspection of this system between 8:30-
9:30 A,M• or 1:00.1:30 P.M. on d of completion, Telephone Numbers 704.634.5985,
Final Installation Diagram: System Installed by
p
Certificate of Completion Dete
'The signing of thle rcertiflcate 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,
y�l WORKSHEET FOR SEPTIC SYSTEM REPAIR PERMIT
NAME ,v A PHONE NUMBER 9 9
ADDRESS _ SUBDIVISION NAME
SUBDIVISION LOT#
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED
NAME SYSTEM INSTALLED UNDER
SPECIFY PROBLEMS OCCURRING
DATE REQUESTED - -3 INFORMATION TAKEN BY