427 Oakland Avenue Lot 148IMF
"NOTE: Issued in Cor
Sewage' Trec,
Name
Location.
DAVIE COUNTY HEALTH DEPARTMENT'
1OVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
Dliance with G.S. of North Carolina Chapter' 130 Article 13c
hent and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Date !�. .3367
T !"' r^r j'9 ✓!; fI'%f 11Y ( is l
Subdivision Name II
Lot Size
No. Bedrooms!
Garbage Disposal
..Auto Dish Washer
Auto Wash Machine..
1voe Water Suboly
'Lot No. Sec. or Block No.
House Mobile Home Business Speculation
-No. Baths _ _ No. in:.Family Z
YES :E] NO _[�% }
Specifications 'for System:
YESNO O YES NO [� NO ,F]
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.
1. Permit Requ
2. Address
3. Property Ow
Home Phone
Business Phone
Address
4. Permit To: a) Install Alter RepairT�
b) Privy Conventional Other Type
Ground Absorption
c) Sub- Divisionec.� Lot No.
5. System used to serve what type facility: H use Mobile Home Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions / 44
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: Public Private Com unity
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions /4-,:Q ��' 100 �' /�(�3 �X%,7'D
b) Land area designated to building site
c) Sewage Disposal Contractor ���� �/''O 5
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 Signat re
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-82)
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