P3070 Sain Rdy DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'Note: Issued n Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name Date F > -7
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 YES ❑ NO ❑ Specifications for System: i
Auto Dish Was er YES ❑ NO
Auto Wash Ma hine YES ❑ NO -❑
Type Water S pply
*This permit V id if sewage system described below is not installed within 36 months from date of issue.
Improvements permit. by
`Contact a repsentative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or :00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985. .
Finallnstallatio i Diagram:
Z�� hALL
System Installed byS N
Certificate of Completion Date
7.2�-YZ
"The signing of his certificate shall indicate that the system described above has been installed in compliance with
the standards sot forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily fo any given period of time.
1
. DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'Note: Issued n Compliance with G.S. of North Carolina Chapter 130—Article 13c.
t, Permit Number
Name Date .� —� 1' ~'
�.,, �1�/r, _ •,. �,. c+�.., •.�– Z � t
Location
J
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 p'` Specifications for System: -t,'+
Auto Dish Was ier YES ❑ NO p'
Auto Wash Ma hine YES p-" NO ❑ r ;�
Type Water Supply
*This permit Vpid if sewage system described below is not installed within 36 months from date of issue.
i
•:
i
0
Improvements permit by
\` \-v! '!
*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:
Z PAI L,
i
8
System Installed by�WA C-0 ( L tj a—, Z- 0—
%
Certificate of Completion ��'"�"' Date
2-
*The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standardslset forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily fpr any given period of time.
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
ONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
l/ Home Phone
1. Permit Requested B y /yluc,e� Business Phone
2. Address i 2 / m_ra-�-
3. Property wner if Different than Above
Address L
4. Permit To a) Install Alter Repair
b) Privy Conventional vOther Type—
Ground
ype Ground Absorption
c) Sub -Division Sec. Lot No.
5. System uc ed to serve what type facility: House —4 --Mobile Home Business
IndustryOther
b) Numbe of people
6. a) If hous or mobile home, state size of home and number of rooms.
Hou a Dimensions
Bed 3ooms 2�— Bath Rooms Den w/Closet
b) If Busir ess, Industry or Other, State: Number of persons served
Wha type business, etc.
Estirr ate amount of waste daily (24 hours)
7. Number aid type of water -using fixtures:
commodes urinals garbage disposal
lavat ry i showers 1 washing machine
dishwasherf sinks Z
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? a -- No
9. a) Prope Dimensions*�-
b) Land a ea designated to building site
c) Sewag Disposal Contractor
10. Do you a ticipate 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.
Date Owner Sign ture
ER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-82)