787 Baltimore RdI'll _
> �- DAVIE COUNTY. HEALTH DEPARTMENT
z IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
"Note:-Issued.in Compliance with,G.S. of North Carolina Chapter 130—Article 13c.
- Permit Number
Name .�r'-.ri. Gcf% r' / a, RDate r���la��� ��;{ �, 3099
s,
,Location
Subdivision Name Lot No. Sec. or Block No'
Lot Size House (Mobile Home _ Business Speculation
No. Bedrooms No. Baths
No. in Family.
e _
Garbage Disposal YES ❑ NO C] Specifications fqr System:'
Auto Dish Washer . f YES .❑:. NO ❑ �'fc> Cj(P
Auto Wash Machine YES ❑ ,NO �❑ riO�
Type Water Supply
"This permit Void if sewage system described bllow isnot 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 on day of completion. Telephone Number -'704.-634-5985.
' P.M.� III
, X
Final Installation Diagram: I'� System Installed by�
U
S�✓S � tr � I�
Cert icatle. of Completion _ Date 2,10 _i�
';�'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; l:,
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME PHONE NUMBER
ADDRESS SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE `r NLQCT .0 LA11-
f�ph,, . M 4hd
DATE SYSTEM INSTALLED �"' NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS 2 NUMBER PEOPLE SERVED
TYPE WATER SUPPLY ��� SPECIFY PROBLEM OCCURRING
DATE REQUESTED INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application.
(SIGNATURE OF OWNER OR AUTHORIZED AGENT
3
Rev. 1193
NO�1Q IrJ
W4LL- .
-rte, 9&tom