155 Westridge Road Lot 29DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Seware Disposal System - G.S. Chapter 130 -Article 13C)
OWNER OR CONTRACTOR I + 1 i t i"^'•-� • (t� • t DATE / % l % PERMIT
LOCATIONl,t r r i' ,•-r� �� �,�,JQr� ' Q� 0� 1303
S.R. NO.
SUBDIVISION NAME 1.bt--i'r'1,C_ LOT NO. aZ SECTION OR BLOCK NO.
HOU
BUSINESS ❑
SIZE OF TANK gal.
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES: 2 `"If
WATER SUPPLY: Individual 9 Public ❑
IMPROVEMENTS PERMIT BY
CERTIFICATE OF COMPLETION
By �
(8/16/73) *Construction must
LOT AREA
House Trailer
Two Bedroom House
Three Bedroom House
Four Bedroom House
-3640 Pt
W -'S -;t704
800
Gal.
400
Sq.
Ft.
NO. BEDROOMS -3
NO.
BATHROOMS
Sq.
GARBAGE DISPOSAL UNIT
YES
❑
NO
25
AUTO. DISHWASHER
YES
C5
NO
❑
AUTO. WASH. MACHINE
YES
NO
❑
SITE SUITABLE cdD
YES
NO
❑
SIZE OF TANK gal.
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES: 2 `"If
WATER SUPPLY: Individual 9 Public ❑
IMPROVEMENTS PERMIT BY
CERTIFICATE OF COMPLETION
By �
(8/16/73) *Construction must
LOT AREA
House Trailer
Two Bedroom House
Three Bedroom House
Four Bedroom House
-3640 Pt
W -'S -;t704
800
Gal.
400
Sq.
Ft.
800
Gal.
600
Sq.
Ft.
900
Gal.
900
Sq.
Ft.
1000
Gal.
1200
Sq.
Ft.
INSTALLED BY L, 9,1 rilp� '
"IW''Yh1 Dat L 112 2-
with all other applicable State and local 4egthations
W C.tr. R c a C�
Ar
1 0 0 0 '\ca.! . '�"d �, k
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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
* NOTE-- Issued in Compliance With Article I I of G.S. Chaq�e�r 130a
Sanitary Sewa a Sys# ms �d��p- Permit Number
-DAir
ate NID' 5794
Ii -
Location c� - - All
2 7
Lot No. 9 Sec. or Block No.
Subdivision Name
- n
Lot Size `House Il Mobile ,Home _ Business Speculation
l
..No. Bedrooms No. Baths P. in Family
Garbage Disposal YES p . NO
Auto Dish Washer YES E] NO
Specifications for System:
Auto Wash Machine YES E] NO
Type Water Supply. �) IL. yx1a
*This permit Void if sewage system described below is not installed within 5 years from date of issue.-
This
ssue.This permit is subject to revocation if site plansl'or the intended use change.
- Ili i .. •
jl Improvements permit, by
i
"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 dayL of completion.Iti Telephone Number: 704-.634-5985.
Final Installation Diagram: 1i4 System Installed by
. , 1. i � •
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 i6'NO be as a guarantee that the system will function
satisfactorily for any given period of time. )I {
ll .��
DAVIE COUNTY HEALTH DEPARTMENT
11'" ;, IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'NOTE; Issued in Compliance With Article II of G.S. Chapter'130a
j ry. C� -
- — �SariitarySewage Systems �; -� �- Permit Number
Name _ 5
7
Location.1�"rrr" /. r•%. f. M :; 'r`r- .z, , -f _! _,
Subdivision NameS �-- Lot No.d; Y?'t, Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms-'"ri�i1 No. Baths _ Z — No. in Family —
Garbage Disposal YES ❑ NO p Specifications for System:
Auto Dish Washer YES ❑ NO
Auto Wash Machine YES ❑ NO
Type Water SuPPIY �' --- •'!`�'���'` ��'r'y,,
'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.
Improvements permit by —La Z%
'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 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.
A
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665 R�Ci
Mocksville, N.C. 27028 )'
CONST
1. Permit Requ
2. Address J
L IMPROVEMENTS PERMIT HAS BEEN ISSUED.
3. Property Owner if Different than Above a2o&f1aA A- ._)& ,CZLeC6kru
Address S/
4. Permit To: a) Install Alter Repair
b) Privy Conventional S�
6j/�Other Type w����!d (y po�"lyy
Ground Absorp 'on /�' Q/,,'
11
c) Sub -Division Sec. Lot No. `(,f�lJ` e
5. System used to serve what type facility: House Mobile Home Business
1., Industry Other
b) Number of people
6. ap If house or mobile home, state size of home and number of rooms.
House Dimensions AQV e52::�Ar
Bed Rooms Bath Rooms -3 Den w/Closet_
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hou
7. Number and type of water -using fixtures:
7'1
commodes 43 urinals
lavatory �� �" showers'
dishwasher / sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yesy No
9. a) Property Dimensions
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipatepny/additionsgr elpansions of the
What type?
TWis to certify t at the information is
Date
this sewage
the
Owner
garbage disposal
washing machine l
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing.
Directions to property:
.� 7 _
atV�
17 �q
it *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.
DCHD (6.82)