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•��J/)) �: DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article 11 of G.S.Chapter13 a
Sanitary Sewage S stemsdi��e Permit Number
Name ,��.�,Q�� Date �P 9� N2 15 9
Loca 'on
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home Business _— Industry
No. Bedrooms No. Baths — No. in Family�:-2— Public Assembly Other
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑, NO_.p_ - / (/ (/ �//i
Auto Wash Ma^hive YES ❑ NO ❑
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.
Improvements permit by 10A/
*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:704-6345985.
Final Installation Diagram: System Installed by ��� �
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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.
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Fes.._ .•wJ{./"- '0VY O
_
u$ Y' DAVIE -COUNTY HEALTH DEPARTMENT
- ya IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLgTI0N1,7 �
*;-NOTE:la�ued in Compliance With Article I I of G.S.Chapter 13 a / a �/
" -{ unitary Sewage Syste,,m/s/ Ax, e Permit Number
t Name^L �r� ��lA Date NO 7597
Local
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home —T Business __ Industry
No: Bedrooms =2—.No. Baths _ No, in Family _ Public Assembly Other
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES [) NO ❑h` .4
Auto Wash Ma;hive YES ❑ NO ❑ /�� �f '� /O �./ � �
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.
r�
lite ell,
Ll
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
s
jJ
f
... •/boy o / —
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 betaken as a guarantee'that the system will function
satisfactorily for any given period of time-.----- ,
1 'V4.j DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
V _ APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME -Os-mofLl PHONE NUMBER
ADDRESSSUBDIVISION NAME
LOT#
DIRECTIONS TO SITE - /-d
v it s e r' ,�c L/,J - Jou IvS //-f-n
DATE SYSTEM I STALLED ? NAME SYSTEM INSTALLED UNDER
TYPE FACILITY 0'/w USS NUMBER BEDROOMS -:2— NUMBER PEOPLE SERVED
TYPE WATER SUPPLY 4ZL?t SPECIFY PROBLEM OCCURRING �`GfS/f�S .5•��
DATE REQUESTED
6 � INFORMATION TAKEN BY li(l�� caEAWT;?, �-
This is to certify that the information provided is correct to the best of my knowledge,
and that I understanddI am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1193