P3379 Country Lane EstatesDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c s
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968)// Permit Number
Name �� %��1:� i ;Date Vii_ r` i'�'aj a► r
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size Housey Mobile Home _ Business __ Speculation
No. Bedrooms No. Baths --- No. in Family _
U c -.._
Garbage Disposal YES ❑ NO ❑
Specifications for System:
Auto Dish Washer YES NO
Auto Wash Machine YES ❑ NO ❑ r �. Gr , t
Type Water Supply
*This permit Void if sewage system des"Nbed.,belo� 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 Diagram:
System Installed by
Certificate of Completion ti,�h 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.
6-1
r _CATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Address
Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
Home Phone ,/
Business Phone lo't-7% Z42
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 162:1- C20
Bed Rooms_,— Bath Rooms— Den w/Close
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 2
lavatory
urinals 0
showers 1_Z_
dishwasher/ sinks I
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes_ZNo
9. a) Property Dimensions
b) Land area designated to building site
c) Sewage Disposal Contractor
garbage disposal
washing machine
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 cor ct to the best of y k ow e.
0 �yv
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)