425 Madison Road Lot 14DAVIE COUNTY HEALTH DEPARTMENT
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lr fl IMPROVEMENTS PERMIT AND.CERTIFICATE OF COMPLETION.
I - *NOTIE:1ssued in Compliance With Article I I of G.S. Chapter 130a
/S/anita Sewage Systems Permit Number
Name Date :L N2 6739'
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LocationI/�fr v �J/✓- //i v"Frei /.% .�Y , �.` _ $'
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Subdivision Name D/IJ
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Lot No. � ��� ec. or Blo Ek No.
Lot Size I"P-2lI1
House
Mobile Home _L_ Business Speculation l�
No.tBedrooms .No. Baths
No. in Family _
Garbage Disposal YES
❑ NO
2 --
Auto Dish Washer YES
4 NO
❑
Specifications for System:
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Auto Wash Machine YES
W NO
❑
Type Water Supply
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*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.
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Improvements permit by _1
*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
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Gertificate of Completion —%�Q�_ Date 'Z
*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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1, Application/Permit Rec
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665 n /�
Mocksville, NC 27028
By
Mailing Address h / —
Home Phone
2. Name on Permit if Different than Above
Business Phone
3. Application/Permit for: ❑ General Evaluation Septic Tank Installation
4. System to Serve:12-House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry
O Other
❑ Unknown
5. If house, mobile home: Subdivision 57�01/i/�lY��J%
Section Lot #
"
No. of People
No. of Bedrooms
No. of Bathrooms
Dwelling Dimensions
6. If business, Industry, place of public assembly, other: Specify type
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No. of People Served
No. of Commodes
No, of Lavatories
❑ Basement/Plumbing
❑ Basement/No Plumbing
❑ Washing Machine
❑ Dishwasher
❑ Garbage Disposal
No. of Sinks
No. of Urinals
No. of Water Coolers
No, of Showers !� Water Usage Figures.
7. Type of water supply: 0-1 ublic ❑ Private
8. Property Dimensions Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No
If yes, what type?
❑ Community
'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, If site plans or the intended use change. Effective October 1, 1989.
Directions to Property:
This is to certify that the Information provided Is correct to the best of
Incurred from this applicatio /
42
DATE
and I understand I am responsible for all charges
SIGNA
CONSENT FOR SIZE EVALUATION TO BE DONE 9N ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property, ❑ 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representative of the Davie County.Health Department to enter upon above described
property located In Davie County and owned by
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
DCHD (1280)