387 Cedar Grove Church Rd (3)r+r.w.:y: ". _: s.. : y:.�... V .f_.*:•..id':EI'>V.•.:.rlr ..!x.13 n•.%t.wi'J•Cii r%.FjK y..F•-•y.§hi[IWdM1":V,'Lli^1Y.•1w.�.Y11:JM�11F.NryaIY it-.'.uM b 'y!�1::'. w.f .•
DAVIE COUNTY HEALTH DEPARTMENT �
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' 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
\t t;•.
Name _�`�a�\�4Z_ {� � � =��, Date
&
Location
Sj�j, •�1��V\ . �� y.�T'.'r... �+�r� `'4C�'- �,�,,.r.A`.?� ��^1J:.�:.
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 p NO 'E�
*.Specifications for System:
Auto Dish Washer YES, p NO .l
•' Y -
_ ��
Auto Wash Machine YES p" NO, p
-
Type Water Supply ---
*This permit Void if sewage system described below is not installed within 36'months from date of issue.
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Improvements permit by —�
*Contact a representative of the Davie County HealthDepartment 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.
:1
anal Installation Diagram:
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�Do' _5 o\�
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V
Certificate of Completion ` (�`T Date o1 l ^ 0
*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:
DAVIE COUNTY HEALTH DEPARTMENT
IV�PROVEMENTS 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 'i �, _21.'•i J$,
Location \ , 1"I • iy�.—., \ \� t't r� iy n e Y J "' i l,!
Ty Yl -.(1 yF 1 �-._ c `�. >3_ �,� —.SKS •\��St% �:.
Subdivision Name Lot No Sec. or Block No.
Lot Size House ` Mobile Home _ Business Speculation
No. Bedrooms T' No. Baths No. in Family
Garbage Disposal
Auto Dish Washer
Auto Wash Machine
Type Water Supply
YES ❑ NO 'S
YES , ❑ NO p
YES ❑' NO ❑
Specifications for System:
`This permit Void If sewage system described below is not installed within 36 months from date of issue.
iN, WN
i J
is
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 C C?�`� 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:
INFORMATION FOR SEPTIC SYSTEM REPAIR!PERMIT
NAME In;lle- A -S -141e- PHONE NUMBER
ADDRESS Y-4, 30 2,21 SUBDIVISION NAME
a. e -
SUBDIVISION LOT #
DIRECTIONS TO SITE d4 d�llrd)
t4
DATE SEPTIC SYSTEM INSTALLED
NAME SEPTIC SYSTEM ORIGINALLY INSTALLED UNDER
SPECIFY PROBLEMS THAT ARE OCCURRING
DATE REQUESTED INFORMATION TAKEN BY
STATEMENT
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
210 HOSPITAL STREET
P. 0. BOX 665
MOCKSVILLE, NORTH CAROLINA 27028
(704) 634-5985
DATE 2-3-88
F -Mike Hester
Rt. 3, Box 221
Mocksville, NC 27028
Repair Permit 5043/Cedar Grove Church Rd.
$35.00
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DETACH AND MAIL WITH YOUR CHECK. YOUR CANCELLED CHECK IS YOUR RECEIPT.
2-8-88 Repair Permit 5043/Mike Hester $35.00
Cedn!7 Grove Church Rd.
BALANCE DUE — 1 $35.00