165 Tadpole Trail (2) ".e;,,,�?$,.:7, �i'iJ: •+.,..iY ,Srk Y- 53 � E.{., � .�;.' r- _;i., ^jLL t� £• •L'•• r.r Y° i.i, � `.r,u,,.. ,,'�:t , a.�-
A �D
DAVIE COUNTY HEALTH DEPARTMENTS-- sD,oc�
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION I1�
•NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems q Permit Number
Name o.�� - 2 S e � �J �-�� _ Date w j ' ly N2 t 5,91
Location
Li V–
Subdivision Name Lot No. Sec. or Block No.
Lot Size 3 Cxs A House 1"0' Mobile Home Business __ Industry
No. Bedrooms No. Baths _ — No. in Family _ Public Assembly Other
Garbage Disposal YES ❑, NO Specificatjorts for System:
tJ - 3
Auto Dish.WasherYES:[I} NO ❑
Auto Wash Ma^hive YES [P' NO ❑ OU X � �/ 1 �' ^'
Type Water Supply " ---'
'This permit Void if sewage system describdd 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.
1
1 Ov'
b c, ,
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 Num�er.704-634-5985.
Final Installation Diagram: System Installed by 106yt!q ..
F
ru
Fal l
Q- 5 9 - 94
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 ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
(3
NAME ��nnfa- PHONE NUMBER
ADDRESS 37y- AlIUM-0-6— SUBDIVISION NAME
�� LOT#
DIRECTIONS TO SITE • , ,C�7- 11 h- �1��9 Yd�e `T�/L ,, � I d GfS� d h-
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY—& NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY Gf�f%�/ SPECIFY PROBLEM OCCURRING S �G�
e
,4�7,q-XA a" ! �y�a�k22
DATE REQUESTED `7 '97' INFORMATION TAKEN BY Cr(),91'
This is to certify that the Information provided Is correct to the best of my knowledge,and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1193