528 Turkeyfoot Rd iK
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Di$posal Rules (10 NCAC 10A .1934-.19/68) Permit Number
Name /- ;%�i J ��i.gi Date11�/ 3282
Location
Location %Z'
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ � Business Speculation
No. Bedrooms ! No. Baths No. in Family
Garbage Disposal YES ❑ NO p---- Specifications for System:
Auto Dish Washer YES NO ❑ �. - ��f� ✓,` ' �,
Auto Wash Machine YES NO �❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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 �� l
Certificate of CompletioDate
*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 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. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone X4-7 7G S�
1. Permit Requested By CX,9-kke RIS�aJ^l' Business Phone - 3
• 2. Address_RZ:,L( 9: �1.1 a dRia 19je. 4-Ak,S
3. Property Owner if Different than Above Clav Ss/ v,r s
Address #
4. Permit To: a) Installer Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home usiness
IndustryOther
b) Number of people 3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions_/ 7 D "
Bed Rooms_ 2 Bath Rooms Den w/Closet 1
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes urinals garbage disposal -4/0
lavatory. showers Z' washing machine :y�S
dishwasher sinks 3
8. a) Type water supply: Public Private__Community
b) Has the water supply system been approved? Yes No_,,�
9. a) Property Dimensions o T '4Gre S
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? h/o
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD(6-82)