134 Jerusalem Ave DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND. CERTIFICATE OF COMPLETION "
'NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Se a Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
J/
Name -Date 211 N2 3703
Location 10 � fL �oz
Subdivision Name Lot No. Sec. or Block No.
Lot Size I/Id t10 House Mobile Home __a�usiness Speculation
No. Bedrooms No. Baths —� No. in Family
Garbage Disposal YES p NO ❑
Auto,Dish Washer YES p NO p Specifications for m:
y e
Auto Wash Machine = YES Ej NO ! %
Type Water Supply,
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
TT
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
Certificate of Completion Date
'The signing of this certificate shall indicate that the system descn ed 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 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 NCAC 10A .1934-.1968) Permit Number
Name .!�/ %; r� /,,> i` ,;.- - Date %�'/�,� %— k 3703
Location i r�.:> - � //,,�',r=�/t"::�:�i•,F; .X�� / ��- 1. l `'>� fir:, .. /iC"/.'i'
Subdivision Name Lot No. Sec. or Block No.
Lot Sized , House Mobile Home_ ^--'-Business Speculation
No. Bedrooms No. Baths No. in Family -
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑ �--� %�
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.
r
l
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.
i" f r
Final Installation Diagram: System Installed by "z ��'--
�,
Certificate of Completion /� C" Date
*Th signing of this certificate shall indicate that the system descri ed above has been installed in compliance with
esg g y P
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 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 and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name l r,' Date ��y.�% !�• 0/ 03
Location '
Subdivision Name Lot No. Sec. or Block No.
Lot Size �1 House Mobile Home _� Business Speculation
No. Bedrooms _' / No. Baths -� No. in Family
Garbage Disposal YES ❑ NO 0 Specifications for System:
Auto Dish Washer YES ❑ NO ❑ i i ter- arr
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.
1
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s
01
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. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by
r
A.1
:i
Certificate of Completion % ;t Date f 1,
*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, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
I Home Phone `� ��•�
,,/ / _Q _
1. Permit Requ sted By f v `�" � � Business Phone � �s•3
2. 'Address o tee. e_ 41,C� !J
3. Property 0i er if Di erent than Above Ar f j,:11 A .2 i
Address e>)( - 2;E2 Pootee
4. Permit To: a) Install Alter Repair
b) Privy tonventional !!�Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Homes
IndustryOther
b) Number of people
6. a) If house or.6iobile home, stpijtg size of home and number of rooms.
House Dimensions
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 / washing machine
dishwasher sinks 3
8. a) Type water supply: Public Private Community—
b)
ommunity b) Has the water supply system been approved?,Yes No-
9.
o 9. a) Property Dimensions . &4"Ao.-
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? !
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 fQr pro essing
o r o
Directions to prop
V-1, "V\.A-
DCHD(6-82)