2058 Hwy 601S (2)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-.196/8) Permit Number
Name Fir^ �� , ��yii: f Date '�� /�X-F 31 (j a
Location
Subdivision Name
Lot No.
Sec. or Block No.
Lot Size 'l��'%� House i-�Mobile Home Business Speculation
No. Bedrooms k No. Baths Z No. in Family
Garbage Disposal YES ❑ NO (2--'
Specifications for System?. .
Auto Dish Washer YES E] NOD � ////, /y. //�J� lei •�� � /'
Auto Wash Machine YES g—NO,.❑
Type Water Supply _
*This permit Void if sewage system describe elow 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 z
*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
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name' Date -, �� �� 708
Location
F�
Subdivision Name Lot No. Sec. or Block No.
Lot Size -lam— House— Mobile Home _ Business Speculation
F f -
No. Bedrooms No. Baths —�L� No. in Family
Garbage Disposal YES ❑ NO Ej., Specifications for System:
Auto Dish Washer YES ❑ NO I _- f -) I
Auto Wash Machine YES- .NO ❑ x /v�� f �'` /
Type Water Supply a �4/, / --- _�
-'
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
l-
L�
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 c� con),pletion. 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 O�
20
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT a,
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 -7-g4' 016--
1.
Is1. Permit Requested By 2,7F02 9E (,cl.YA R ► S Business Phone
2. Address 2 Al �o x /� 5� /V�oeKsyi //E, /1� f✓ .
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people 3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms 3 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 garbage disposal
lavatory showers (Tye) f washing machine y
dishwasher sinks -/
8. a) Type water supply: Public ✓' Private Community
b) Has the water supply system been approved? Yeses No
-
---9. 9. a) Property Dimensions
b) Land area designated to building site
c) Sewage Disposal Contractor Ecl. F%sNEQ Pl ur+ b � � � Sep. $ y( 9117 jaW. pp 2 7-o
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 4r Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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