1630 Yadkin Valley Rd (2) 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 Disposal Rules (10 NCAC4:10A .1934-.1968) Permit. Number
Name , . ` ' Date
Location
1 '
Subdivision Name Lot No. T Sec:or Block No.
Lot Size House –''Mobile Home — vsiness Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ;Q NO E]
j Sp cj1i6 tions for System:
Auto Dish Washer YES NO
Auto Wash Machine YES Lll NO p ,
Type Water Supply ✓, A
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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-; Y, r
j
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
il„;:
' ..
Certificate of Completion �'�� �=GYr[ 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 l
Environmental Health Section ? '
P. 0. Box 665 6
�yv
Mocksville N.C. 27028 bJ
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone qq'P`
�7
1. Permit Re est d B0�v
Business Phone -
2. Address. 76 33
G
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter—
lter Rep�airr
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec Lot No.
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people
6. a) If house or mobile home, stat size of home and number of rooms.
House Dimensions 41t A 30
Bed Rooms Bath Rooms Den w/Closet
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
lavatory showers a washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved?
s V No
9. a) Property Dimensions o �
b) Land area designated to building site S e t tT� v'a 11 a
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? 1y`R7
What type?
i
This is to certify that the information is cor ct to the best of my knowled
Signature
Owner Si I,
Dae g
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
C
DCHD(6-82)