301 Granda Drive Lots 91-93A DAVIE COUNTY HEALTH DEPARTMENT
174 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 //,r -/ '. �` a 6r 4
%!
Location
30/ OR 30-7
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms No. Baths ' No. in Family
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑
Auto Wash Machine YES E] NO ❑ ��'�%^ =•/
Type Water Supply
*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
,t"
Certificate of Completigji; � 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 Heallh Section
R O. Box 665
Mocksville, N.C. 270213
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Pormit Requested Ey _PA27Z__kL1 7'Le d . usigl 'qs P?Par)ea-y� d d
/ �__.�_
2. Address,
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Z Alter Repair
b) Privy Conventional Other Type_
Ground Absorplion
c) Sub -Division" -6—u, r Sec..el ____ Lot No. 9'Z'
5. System used to serve what type facility: House-- Mobile Home_ k!f'Business ..
IndustryOther,
b) Number of people .
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 14 X 76 —
Bed Rooms %,? Bath Rooms_. a- Den w/Closet_—__�
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amouni-of waste daily (24 hours)-
7.
ours) 7. Number ancI type of water -using fixtums:
commAes °L urinals _ garbage disposal
lavatory ----a showers _ .2. _ _ :washing Machine__Z _____._
dishwasher sinks —____
8. a) Type water supply -.Public- ✓ Private-- Community
b) Has the water supply system been z,pproved? Yes ✓ No
9. a) Property Dimensions 'fin %, _ � ba—
b) Land area designated to building site
c) Sewage Disposal Contractor &-
10.
�►s;� r -
10. Do you anticipate any additions or exp-ansions of the facility this sewage system Is Intended to serio? � _—
What type? 41 ----------- ---
This is to certif}, that the information is correct to the best of my knowledge.
X��
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 clays for processing
Directions to property:
OCHO Wal)