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109 Spry Ln .` DAVIE COUNTY HEALTH DEPARTMENT " IMPROVEMENTS .PERMIT AND CERTIFICATE OF COMPLETION, . *NOTE:Issued in Compliance With Article 11 of G.S.Chakter 130a Sanitary Sewa a Systems Permit Number Name ��`N � ti<�s.° Date -� N' 7812 Location .b . '�,0 S ��c v�t.c a r.�C _ �0 0 G — 1,LA a 'vA )A !6R "Z�' CIS A \A,. Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _ Business -- Industry No. Bedrooms .No. Baths — .No. in Family r Public Assembly Other Garbage Disposal YES ❑ NO 6�' Specifications° for System: Auto Dishta-.hine sher YES l NO [j /GVo Auto Was YES NO ❑' l , Type Water Supply "A O *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. t= i `r 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., 1:00-1:30 P.M.or 4:30-5:00 P.M.on day of completion.Telephone Number:704-634-5985. Final Installation Diagram: System Installed by 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. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Re qu sted By ^ ©�IV .. Atr` f /Z,/O Mailing Address Home Phone 9W -7 (/ VC 2 22Y, Business Phone 2. Name on Permit if Different than Above 3. Application for: d General Evaluation Septic Tank Installation Permit 4. System to Serve: ❑ House Q/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 No. of Bedrooms 2-"rNashing Machine No. of Bathrooms CR"Ibishwasher 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: VrPublic ❑ Private ❑ Community 8. Property Dimensions J, 7c;� /gc✓, Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No 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: 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 incurred from this application. 3 -9 �I Afi'�ASLJA - DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 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 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(1193)