P7123 Hwy 158�...,..,r.-,7;av^w.v..j-v✓.iVssrcFw�dwf^o�.�f�t�'+""'�'a^r^iM'ir"o+r�'wavy^-'.by°f�+'Mrwcr'�iRL—.".'Y;a+'^.Y.SPS;osw�.MrtW4;.>hr.kw�+r�Y�.+r.-w
., DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article 11 of G.S. Cha p�er 130a
Sanita ewage Systems V,� Permit Number
3s' r _1/lam 0
Name � , nn �' �/! Date N � 7123
Locatio �S�' !P 0nd /�'� o YUP r 4elf (��i�e l /� ��iC-
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 ❑ aa
Auto Wash Ma :hive YES ❑ NO ❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
l�rp�r��f
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:
S 1
System Installed by v /
Certificate of Completion A/1", Date4Q-3
'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.
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DAVIE COUNTY HEALTH DEPARTMENT �\
IMPROVEMENTS PERMIT AND. CERTIFICATE -OF COMPLETION
/ *NOTE: Issued in Compliance With Article I I of G.S. Chater 130a
_ Sanitary ewage Systems �, F Permit Number
Name 1��ai?�1�, �?�.j �U% `/; ,t Date ��/N2 1 -y 2
Location a'd%-
,t —
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 ❑
Auto Wash Ma.hine YES ❑ NO ❑ /�vX � � y� 1-����
Type Water Supply
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change. r
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 v
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 ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME YQ�wP-z PHONE NUMBER 63'! 3.5'38'
ADDRESS SUBDIVISION NAME
�Yjao,�do-%/lC ISG• Z7o 2�' LOT #,�,��
DIRECTIONS TO SITE �-S8 - B�-riK .�.� �.,��.,. Adla-1 lla4d W /_�L�..� ....�� l iuJ�
kre-
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS 3 NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED 4el- l' INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93