P3963 Liberty Church RdI, DAVIE COUNTY HEALTH DEPARTMENT 1
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c ;+
Sewage Treatment and tDisposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name Date 3963
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House ,__--'_Mobile Home _ Business Speculation
No. BedroomsNo. Baths No. in Family'_
Garbage Disposal YES ❑ NO ❑ , Specifications for S stem:
Auto Dish Washer YES ❑ NO ❑ /
Auto Wash Machine YES ❑� NO -❑
Type Water Supply /- /
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
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Improvements permit by _
*Contact a representative of the Davie County Health Department for final
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number:
Final Installation Diagram:
System Installed by
ion of this system between 8:30-
9985.
J
Certificate of Completion %%y'/ Date JAG
"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
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
L. Home Phone
1. Permit Request e BBusiness Phone
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install L -Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division Sea Lot No.
5. System used to serve what type facility: House obile Home Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms_ 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 washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions : �t
b) Land area designated to building site
c) Sewage Disposal Contractor
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 best of my knowledge.
01
Date 7ZIL 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)