350 Martin Luther King Junior RdI � r: i
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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTlf; Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.19/68) �I I «� Permit Number
Name �rr���-,I'� 11
��, t,Date!%.
Location
Subdivision Name Lot No. _ Sec. or Block No.
Lot Size House Mobile Home -� Business Speculation
No. Bedrooms No. Baths No. in Family —
Garbage Disposal
Auto Dish Washer
Auto Wash Machine
, Type Water Supply
YES ❑ NO p
YES NO ❑
YES p NO {]
Specifications for System:
*This permit Void if sewage system described below 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
Cl 3
J
Certificate of Completion Dated/`
*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.