152 Casa Bella Drive Lot 14DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
0 Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name
Date 31 n 2
L/
Location
Subdivision Name Lot No. --1 —4 Sec. or Block No. & - F
Lot Size. House Mobile Home Business -- Speculation
No. Bedrooms No. Baths No. in Family
-...Garbage Disposal YES F-1 NO -E]-- Specifications for -System:
�,,.,-,&uto Dish Washer YES NO Ej
Auto Wash Machine YES NO
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
F-- -
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 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.
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APPUCATION FOR SITE EVALU,N'r ION/ IMPROVEMENTS PERMIf
Davie County Health D,tpailment
Environmental Health Sec-flon
P 0. fk)x 665
Mocksville. N.C. 27023'
CONSTRUCTION SHALL NOT SEGIN UNTIL IMPMWEMEN7S PERMIT HAS JWFN 1SWIiij
Home Phone
27"'
1. Pormill Requ ted By T_J&5�1'7-tl .�TAI-90 Buslnessl*h�ne
2. Address — 70) 4? OX c
Propwty Owner If Diftent than Above
Addre=
4, PerrrJt To: a) Instafl.A:n'_Att&r_ Repa I r—
b) Privy— Conventional_±!f`6ther Type_
Ground Absorplion
c) Sub -Division Sec:—Z-- Lot Nc,.;4y—:--
S. System used to serve what type'facillty: House—_ Mobile Home -K— Elusineos—
Indust,y__ Othcr--.
b) Number of people
a) If hoLze or mobile home, state size of home and number of rooms.
House Dimensions - ZF' 7Q.—_
Bed Rooms 3 Bath Rooms -.-.A-- Dan w/C;Ioset--
b) If Business, Industry or Othar. State: Number of pef90113 seried
What type business,
Estimate amountof waste daily (2-4 hours) -----.--.--
7. Number anq type of water -using fixtures:
commAes garbage disposal
lav3tory .2 showers washing rrischline—
dishwasber sinks
& a) Type water supply: Pubric F'rivaje----- Community --
b) Has the water supply system been approved? Yes_e!:'_"No_._
9. a) Prop(nty Dimensions 16 0 X /S
b) Land area deisignated to building
c) Sewage Disposal Contractor 9!�g
10. Do you anticipate any additions or expansions of the facility tt..is sewa!Ie system is Intended to serve?
What type?
This Is to cortify that the. information is corr ct to the best of my knowledge.
9 7
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIAN:;E WITH ALL STATE AND LOCAL LAWS
Allow 5 �tays for processing
Directions to property*
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CA -
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