736 Sain Road Lot 4IMPROV
E COUNTY HEALTH DEPARTMENT
TS N PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in ComplianceG.S. of 'North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1 68)
1934-.1968) Permit Number
Name Date
Location
'3& 5,+iAl U -
Subdivision Name !!;;QkZ&` CE16!26e 5' Lot No. Sec. or Block No.
Lot Size House Mobile Home Business Speculation%
No. Bedrooms
No. Baths 2- No. in Family
— 3
Garbage Disposal YES ❑ NO 2— Specifications for ystem: 17
Auto Dish Washer YES NO 0 Alwve)
Auto Wash Machine YES NO C]
Type Water S upply
*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 p4ram: System Installed byALjjj k JULOLk
Olt"
0% U
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.
l` DAVIE COUNTY, HEALTH DEPARTMENT
IMPROVEMENTS -PERMIT AND CERTIFICATE OF COMPLETION'- _
*NOTE: Issued in Compliancg wi#1 'G,S. o)fN'orth Carolina Chapter 130 Article 13c = _ - - . •' - '
Sewage Treatment and Disposal Rules (10 NCAC 10A.1934-.)968)-- Permit Number
Name 64/Z '' 1fir: 9!5) Date
Location
Subdivision Name Lot No. Se -c --or Block No.
Lot Size House Mobile Home _ Business S Icuhatton1+ �C
Y '
No., Bedrooms - No. Baths ," No.. in Family
Garbage Disposal 'YES ❑ ' NO
Specifications for System:
Auto Dish Washer YES NO
;Auto Wash Machine YES W NO fl
Type Water Supply
*This permit Void if 'sewage system described below is not installed within 36 months from date o4issye. - `3
.0
I. I . '• III, .. ..
Improvements permit. by,
*Contact, a representative of the Davie County Health Department for final inspection of4kthis 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 Pn.. st1 fL
NeII
1' �4
' �Y �►� I �• fes. '
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 forthin 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.
Home Phone b �D
1. Permit Requested By ss Phone 7y V— a O
2. Address A± i
3. Property Owner if Different than Above
Address
4. Permit To: a) Install 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 Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions .� 9 x 09
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
8. a) Type water supply: Publics Private Community
b) Has the water supply system beenap� �prro,,��ed? Yes No
9. a) Property Dimensions �'-u' `�"` A D ,
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 best of my knowledge.
,U 12`
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)
,.