P3173 Davie Academy RdDAVIE COONTY HEALTH. DEPARTMENT
IMPROVEMENTS PERMIT AND: CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130 -Article 13c.
'' Permit Number
Name i:R��: L Sv�a �ht.� Date l — ho —SC 3 N? 3173
Location ,rL2%c�io l tGl- .47-', d4elle< 10.4 ,;e lie. e�ZIJL 4: D:�lu�e
Subdivision Name Lot No. Sec. or Block No.
Lot Size House J Mobile Home_ Business Speculation
No. Bedrooms No. Baths 2-' No. in Family 2'
Garbage Disposal YES ❑ NO ❑ Specifications for System: T41A
Auto Dish Washer YES ❑ NO ❑ �Z .�, d,F_ 2 00�1� g•X�Z•• �.<<C
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.
Qe•D
a
Improvements permit by • Yea' '�`�
*Contact a representativeof a Davie County Health Department -for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. n day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed byU��
Certificate of Completion Date
"The signing of this certificate shall indicate that the system'describ d 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
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name Date
0 /J
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal
Auto Dish Washer
Auto Wash Machine
Type Water Supply
YES ❑ NO ❑
YES ❑ NO ❑
YES ❑ NO ❑
�,..-
Specifications for System:
*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 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
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77
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t
1
i 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.
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name l' VC, L Date I - o — l 3� •�
Location .%rW 1 AJ- i; blel
Subdivision Name Lot No. Sec. or Block No.
Lot Size House '� Mobile Home _ Business Speculation
No. Bedrooms No. Baths z• No. in Family Z
Garbage Disposal YES ❑ NO ❑ Specifications for System:,, •,,- 'i ,>>� -
Auto Dish Washer YES ❑ NO ❑ 7 o o' r, Z �,•�.
Auto Wash Machine YES❑ NO 0
lii7G(.�� w -
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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t
I Improvements permit by��-'-
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*Contact a representative of tl,e Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. �n day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed bye --mow"
Certificate of Com letion J°��% �< Date " 2-1
P
*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
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 2— 7 3 7 2
1. Permit Requested By —Business Phone
2. Address 2+- 7 13 1C S519 Awac�e 2 70 2 P
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair--L'--
b)
epairy
b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House `f- Mobile Home Business
IndustryOther
b) Number of people 2
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms 3 Bath Rooms Z 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 ers
dishwasher inks
8. a) Type water supply: Public Private ✓ Community
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
garbage disposal
washing machine
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 the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6.82)
.Ti'61'a /4!""— i , e! �//- a-1