P3483 Wood Valley Lot 2DAVIE COUNTY HEALTH DEPARTMENT
' IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
wage a ment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name Date _a 3483
Location , Z
Subdivision Name Lot No. Seca or Block No.
Lot. Size House Mobile Home _ Business Speculation
No. Bedrooms 3 No. Baths No. in Family _
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO C] -
�Gc�'X
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.
i
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 byF CoRNAT2£,L
Certificate of Completion -?���� DatL
*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 FOP: 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.
FOO Ph 9P
:. Permit Req steel By 5 ?! t Ty_ _ tl e_ Bu in s& r�herpe �� dy _
2. Address 2t---
3. Property Owner if Different than Above
Address _
4. Permit To: a) install Alter Repair
b) Privyr Conventional Other Type__._
Ground Absorption
c) Sub-Division,9-d/l ;59 Sec. Lot No.
5. System used to serve what type facility: House Mobile Home f31tsine$s.
industry_ Other-_.
b) Number of people
6. a) If house or mobile home, state size home and number of rooms.
House Dimensions�LL�� .
Bed Rooms Bath Rooms_ _el Den w/Closet r
b) If Business, Industry or Other, State: Number of persons sorved
What type business, etc.
Estimate amouni'•of waste daily (24 hours)-
7.
ours) 7. Number and type of water-u6ing fixtures:
commodes urinals_ garbag,p disposal
lavatory �.2� showers_z ;Kvashing mschine_�
dishwasber sinks "
8. a) Type water supply: Public_ P-' Priva;e Comm unity--
b)
nity _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? /10
What type? _._ - - -
This is to cortify that the information is torr t to the best of my knowledge.
Date Owner Signature
OWNER to SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
WHO (6.82)