160 Lybrook Road Lot ADAVIE 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 Date 6— Z -83 3302
Location
Subdivision Name eq '61'e, ' t rwl"j 1c// 1, Lot No. A Sec. or Block No.
Lot •Size ;1,2i�. 314 6-en, House Mobile Home _ Business Speculation
No: Bedrooms 3 No. Baths - No. in Family_
Garbage Disposal YES g NO ❑ Specifications for System: ic7dr�
Auto Dish Washer YES NO ❑ -/
j00 A iii/2r �u[K
Auto Wash Machine. YES 0" NO fl 3, .,-
Type Water Supply
..*This permit Void if sewage system described below is not installed within. 36 months from date of issue.
Ana &:e_
Improvements permit by��^ l
*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
PE) --2'
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 betaken as a guarantee. that the system will function
satisfactorily fo_r;anygiven period of time.
sN ,ffar✓
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department' t� Y
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
nn Home Phone %,2 3' G o9,?
1. Permit Requested ByF�,9 /��� L AA11V R Business Phone
2. Address L!g G 41,,4 4 �Z AVE wl tf (.TQy - SA I..cM /l/ C a 7 / 0 /
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 &, n A FF k� Sec. Lot No. A
5. System used to serve what type facility: House - Mobile Home Business
IndustryOther
b) Number of people 1
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions SC k 3a'7 "
Bed Rooms 3 Bath Rooms Z? 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 y urinal
garbage disposal
lavatory y showers washing machine /
dishwasher t sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes r No
9. a) Property Dimensions 13S x z25- x Xj- x .2z
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? /y0
What type?
This is to certify that the information is correcttothe best of my knowledge.
G A /83 )92 �f1�r�tpJ1J
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)