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310 Gladstone RdQye ti �,:. . cS ng, o- •' DAVIE COUNTY HEALTH DEPARTMENT a' 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 , � k/%I "x/I/ r i Date 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 p NO [� Spec ifications,for..System: Auto Dish Washer, YES N0 Auto Wash Machine YES NO ,E] L. Type Water Supply __- 01, "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. r 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 Dated -y�: ���#8 < r i . / c• iV�� 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_[] - Specifications for System: Auto Dish Washer YES,,[] NO E] Auto Wash Machine YES p 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. t lY 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 4-I�_Aq MUM=- .: rrroaff�fas 3. Property Owner if Different than Above Address 4. Permit To: a) Install Alter Repair b) Privy Conventional Other Type Ground Absorption c) Sub-DivisionSe . Lot No. 5. System used to serve what type facility: House Mobile Home Business IndustryOther b) Number of people, 6. a) If house or mobile homestat size of home and number of rooms. House Dimensions d0h)7 Rhh .c) Bed Rooms Bath RoomsTDen w/Close 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 I showers dishwasher sinks 8. a) Type water supply: Public ✓ Private Community b) Has the water supply system beeappr ved? Yes / No 9. a) Property Dimensions���1m4An b) Land area designated to buildipg site, c) Sewage Disposal Contractor ��/,��4U/1711' 10. Do you anticipate any additions or expansions of the What type? garbage disposal washing machine lity this sewage system is intended to serve? 120 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)