113 Sonora Drive Lot 1BDAVIE 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 �j `�� , ✓ f �•
f t !.a
Location
113 fan
Subdivision Name ��` rr�. "�' %= /� % %` Lot No. "' Sec. or Block No.
Lot Size
No. Bedrooms
Garbage Disposal
Auto Dish Washer
Auto Wash Machine
Type Water Supply
House Mobile Home �� �" Business Speculation
_ No. Baths No. in Family_
YES 0 NO ❑ Specifications for System: ")
YES ❑ NO X
YES Q NO ❑;
`This permit Void if sewage system described below 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 /f, ri1 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.
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028 RECEIVED MAR 2 6 19$
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Request By P� ! e • Business Phone
d
2. Address /V-6.
3. Property Owner if Different than Above
Address
4. Permit To: a) Install I'- Alter Repair —
b) Privy ConvOntional `Other Type
Ground Absorption l
c) Sub -Division k12160 1 NI- Sec. ot No.� !3
5. System used to serve what type facility: House 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 L4 X 6f
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 Community
b) Has the water supply system been approved? Yes -�No
9. a) Property Dimensions Z® ®
b) Land area designated to building site 7
c) Sewage Disposal Contractor ea r N A TLE/'
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 Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD (6-82)
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