P4360 Hwy 601SDAVIE 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
f
Name �• �—,� 1r'�;✓ �'%
. rel �, •
,tea
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Date
* .
Location
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Subdivision Name
Lot No
i
Lot Size/� � 4' L— House 1 Mobile Home
No. Bedrooms ,y'"' No. Baths No. in Family.
Garbage Disposal YES ❑ NO _0.—
Auto Dish Washer YES , NO ❑
Auto Wash Machine YES j NO ❑
Type Water Supply
*This permit Void if
Sec. or Block No.
Business Speculation
Specifica
tions for System: ,
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:
Certificate of Completion f�! �� // 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.
•' APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested By
2. Address Ai
w '4/'_ 40,
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Iter Repair
b) Privy Conventional Other Type
Ground Absorption
e
Home Phone 51
Phone
G 2'2(Sz P
c) Sub -Division Sec. 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 home, state size of home and number of rooms.
House Dimensions do S % T�
Bed Rooms 2- 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_
lavatory showers
dishwasher
sinks
8. a) Type water supply: Public r/ Private Community
b) Has the water supply system been approved? Yes No_L_
9. a) Property Dimensions / 0. c. r e S
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? /L d
This is to certify that the information is correct to the best of my knowledge.
;L 0 �q 0- V g , 6— — / 1/1 2! Kip�
Date Owner Signa re
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
'M (t l
DCHD (6-82)
I-
r o-s�'er-