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DAVIE COUNTY HEALTH DEPARTMENT
• 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
Nam
���) Q Date cl -�_-S f� gar,'
Name
Location
v- �? ��b�y.-�,►� - 1, 1 � i - \off' C'
Subdivision Name Lot No. Sec. or Block No.
Lot Size House ^ Mobile Home _ Business Speculation
No. Bedrooms Baths No. in Family 3
Garbage Disposal YES 0` -.NO
Spec
Auto Dish Washer YES ❑ NO 'ificationsKfor System:
Auto Wash Machine YES` [( NO x 3
Type Water Supply �j ZI
'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 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.
s....-. 'r ca .«:.yrs.: ti y ;... ..,. ,, _ ,r,yr ;:.; .i+:`sv`tsir.'. p;»..'*re..;,,.F ..w, ,.. o�-. ., ,.• y„�
DAVIE COUNTY HEALTH DEPARTMENT
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 ^�, ��;c �1� `' ,C C Date I
J
Location
Subdivision Name Lot No. Sec. or Block No.
L
Lot Size House Mobile Home _ Business Speculation
No. BedroomsNo. Baths _�_ No. in Family 3
Garbage Disposal YES .0 NO 'M Specifications. for System:
Auto Dish Washer YES ❑ NO
Auto Wash Machine YES V NO 1
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 by — ji —S�
`ig
Certificate of Completion ~ Date 1 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. •y
" INFORMATION FOR SEPTIC SYSTEM REPAIR PERMIT
NAME �� Q �S PHONE NUMBER
ADDRESS g p SUBDIVISION NAME
SUBDIVISION LOT #
DIRECTIONS TO SITE �j Q 1 S - -�
DATE SEPTIC SYSTEM INSTALLED V tin Q��M
NAME SEPTIC SYSTEM ORIGINALLY INSTALLED UNDER
SPECIFY PROBLEMS THAT ARE OCCURRING
DATE REQUESTED �1-`�� INFORMATION TAKEN BY �