P3350 County Line RdDAVIE -COUNTY HEALTH DEPARTMENT
a-
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Lot Size ,�%�
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit
Number
Named
No. Bedrooms 4N No. Baths
Date "�/ „ ''
Garbage Disposal
:-yV
-� _�a3�a
Location
YES ❑ NO
Auto Wash Machine
fA��'T
T /
Subdivision
Name
Lot No. Sec. or Block No.
Lot Size ,�%�
House
Mobile Home ,>� Business
Speculation
No. Bedrooms 4N No. Baths
No. in Family_
Garbage Disposal
YES ❑ NO
Specifications for System:
Auto Dish Washer
YES ❑ NO
Auto Wash Machine
YES ❑ 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 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.
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
1 R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone g g ?
1. Permit Requested Bye---F//'� Business Phone We 7T
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install A�Alter Repair
b) Privy Convention al��Other Type
Ground Absorption
c) Sub -Division ec lot No.
5. System used to serve what type facility: House obile ome Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions /OX/yO
Bed Rooms— Bath Rooms Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water -using fixtures:
commodes urinals
lavatory showers
dishwasher sinks
8. a) Type water supply: Public PrivateZ,-' Community
garbage disposal
washing machine
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions -
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify that the information is correct to th a of y k ow edge
Date er Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to p
L7A11
7' '1,
DCHD (6-82)