P3754 Rainbow RdDAVIE 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 : , ,', �, /�:
s J 4
Location
/Lot
Subdivision Name No. Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms No. Baths —— No. in Family ~' —
Garbage Disposal YES ❑ NO
Specifications for System:
Auto Dish Washer YES p NO ❑
�y�=>ti� <:r�T ;:, .%r ,,–
,
Auto Wash Machine YES P NO .❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
49
41
I i
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1
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.
System Installed by
Final Installation Diagram:
Certificate of Completion r – ���' ,`� 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
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone „a - 60S 7
1. Permit Request d By vB Business Phone 63H -62y/
2. Address 3% v
3. Property Owner if Different than Above SAME
Address
4. Permit To: a) Installer 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—Z—',
ome Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions /'yx 'A°
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 2
lavatory Z
dishwasher
urinal
showers
sinks
2
garbage disposal
washing machine
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions
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 the best of my knowledge.
// /'P 8V � � X/�
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
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