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DAVIE COUNTY HEALTH DEPARTMENT
~ IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issuedin Compliance With Article 11 of G.S..Chapter 130a
S itary Sewage Syst s .� _' Permit,�10 6 4 r
Name _ Date N2
Location �3 °'� 3 `i �. v a N c>
Subdivision Name Lot No. Sec. or Block No.
Lot Size `House Mobile Home _ Business a r_ Speculation
,.
3 � .: 2 4
No. Bedrooms .No. Baths -1No. in'Family.
Garbage Dispual... YES, ❑ NO j Specifications for System:
Auto Dish Washer .,,.YES
❑ NO �. - ` 2 "^
1► Sti
Auto Wash Ma^.hine YES NO 6
Type Water Supply —
' 6
*This permit Void if sewage system described below is not s alled within 5 years from date of issue.
This permit is subject to revocation if -site plans or the inten use change.
0
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F
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t
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.
Installed b
System
Final Installation Diagram: S Y Y
Certificate of Completion Date
�1
'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.
W
17
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF .COMPLETION
*NOTEAssued in Compliance With Article II of G.S. Chapter 130a
_ Sanitary Sewage Syste st _ �, cj Permit�I�l{Itrtlher
Name Date NO
Locati/gn
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 �= c,
Specifications for: System:
Auto Dish Washer YES p NO ❑ C� t ^ ; ,
Auto Wash Ma hine YES E:] NO ,p
'V
Type Water Supply
u'1�
':This permit Void if sewage system described below is not i sialled within 5 years from date of issue.
This Permit is subject to revocation if site plans or the intend b,gse change.
Improvements permit by
"Contact a representative of the Davie County Health Department fpr final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Num'ber 704-634-5985. �—
n
Final Installation Diagram:
System Installed by A���` (, J� /i/ /
—7
i
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.
j -/S- y 3 ice- 4�
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION��' �p- s
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME PHONE NUMBER �IGI�' PG 9D
ADDRESS P 2 6!2� 211 3 404r& -t4 Z?°'G SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE iso/ -s % -lAocy ✓rtes - 16 8a/ - -/- IGI — GI,C-C 2)"4 „t A_ 4444.1-
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY P�• 90^'-- NUMBER BEDROOMS 3 NUMBER PEOPLE SERVED
TYPE WATER SUPPLY iae I SPECIFY PROBLEM OCCURRING Stwac, coy -
0
DATE REQUESTEINFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge," that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT,
Rev. 1193