2692 Farmington Rd (3)DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION , t
*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 r' „ Date T i ` GJ� as ✓ /
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 YES ❑ NO,n- 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: , au �,t ,`�+�'�' ui - System Installed by CD �' A
w c f1 u! 5
� Cp✓!tea ^-...
f�' 7
\ •f
ol Y ✓
tx�'� C�
r
Certificate of Completion '` ��� �^^ �� Date " Z S
'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
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone ``1 t RY qC1R –3!a9
' uerm
�d!`Pit Requested By . ILK COMO-WO-6 (� Business Phone �'i1
2. Address 12--x- a, 2" 1 R S Akocks0 M P.; • C - a -r a a.
3. Property Owner if Different than Above SOS-rrm C
Address �`�• t Rc5y,- io in 11/tDC,k.S6 �N e -
N •C• "�� Oa,�
4. Permit To: a) Install--ZAlter Repair
b) Privy ConventionalL Other Type -
Ground Absorption
c) Sub -Division Sec. Lot N
5. System used to serve what type facility: House o. Mobile Home Business
IndustryOther
b) Number of people of
6. a) If house or mobile home, state size of home a number of rooms.
House Dimensions—
Bed
L%t X '7 to �(o scL,
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 c�, urinals garbage disposal
lavatory 3 showers washing machine
dishwasher �— nks
8. a) Type water supply: Public �� Private Community
b) Has the water supply system been approved? Yes + No
9. a) Property Dimensions rl • O 4 0-Cre's —
b) Land area designated to building site
c) Sewage Disposal Contractor ea W o– I kC-+(- C
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? b
What type?
This is to certify that the information is correct to the best of my knowledge.
�a- P9 -pe
Date wner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
" va/L4�' at�il
V-6 0rvss-rmp(-S.
C q ss roa�dS 5-P7 l trnalq ,
" ., -
oa��o
Nein
T, �0 , r(,k_0J"-tjy` 4
DCHD (6-82) 1
0dz+r*1 J