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5 ; DAVIE COUNTY HEALTH DEPARTMENT S"
,t
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a
S nitary Sewqqe Systems Permit Number
Name / �1"r c11, Date 7099
Location y/,li-'
Subdivision Name Lot No. Sec. or Block No.
Lot Size Housey Mobile Home _T Business Speculation.
No. Bedrooms ly No. Baths— No. in Family__
Garbage Disposal YES ❑ NO 2-- Specifications for System:
Auto Dish Washer YES NO ❑
ec
Auto Wash Ma :hive YES NO ❑ �� �� '"�
Type Water Supply
*This permit Void if sewage system described below is not i?stalled within 5 years from date of issue.
This permit is subject to revocation if site plans or the i je�ded 7X
ge.
Y
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- 85.
Final Installation Diagram:. System Installed by
F
P�
Certificate of Completion G< 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.
},. .. ;r. ., Ei F� .i'v>� ;,,rq ,z i^�i ,:-'F+ems .. ,h 1w.,�. ..:�•x„e. d+t:,,.,e ;._ .:., rti R --- .tfi,: ,!` .k t.
�- -_ - DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article I I of G.S. Chapter 130a
S nitary Sew Cge Systems Permit Number
-Name Date ��'�` i's'' No 7099
Locations
Subdivision Name Lot No. Sec. or Block No.
y Lot Size House Mobile Home —� Business -- Speculation
No. Bedrooms No. Baths �2 No. in Family
Garbage Disposal YES ❑ NO (3— Specifications for System:
Auto Dish Washer YES T NO ❑ �}
Auto Wash Ma thine YES NO ❑ oS XS K`
Type Water Supply /1� V1
*This permit Void if sewage system described below is not,nstalled within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended u so c drge
. J
Improvements permit by
*Contact a representative of the Davie County Health Department for final inspecti
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number 704-634-!
Final Installation Diagram:
System Installed by
of this system between 8:30-
s
/V11y5
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.
r DAVIE 6bUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME Q �� (� ��, `x� 4:� a PHONE NUMBER
ADDRESS i&` 2/ems SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE ��✓ alp' �C�' ✓-& 71-9 Ad�VJr`
a."� / oele
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY 41YCNUMBER BEDROOMS -� NUMBER PEOPLE SERVED_
TYPE WATER SUPPLY_,` SPECIFY PROBLEM OCCURRING
DATE REQUESTED /�%/�� INFORMATION TAKEN BY 1Zz &
This is to certify that the information provided is correct to the best of my knowledge, a I understafid I a apo able for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1193