P3892 La Quinta Lot 13DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
S wage Treatment and Disposal Rules (10 NCAC 10A .1934-.1 68) Permit Number
Name Date N2. 3892
Location-1��✓,
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:
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.
rye, _c
: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.
42
Final Installation Diagram: System Installed by
Certificate of Completion Date
77
*.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. .
`
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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
. NDTE� |aouedinComp|ian���kh(3�S�of ort Caro|ina{�haubar13O Article 13c
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- S Permit Number
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Na'e Date 3092
Location
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Subdivision Name ^~^'`~
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Lot Size Hou ae-_-_--__-y�obi|eHome _-��___--Business -___-_-_Speculation
-__-__--_
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No Bedrooms -=~e��----No. Baths -_-_-_---�No. inFamily
_---_-___'
GarbagoDisooua YES [] NO E] Specifications for System:
Auto Dish Washer YES [] NO C]
Auto Wash Machine YES [] N[]�]
.
Type Water Supply
'
'
*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 ingpection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 7O4'G34-5985. ,
---
Final |nabu|aUon Diagram: System |nobd|ed by
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Certificate ofCompletion 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 systemwill function
satisfactorily for any given period of time.
_
' `
DAVIE 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 : �' r a C
Location
Subdivision Name Lot No./ - �� Sec. or Block No.
Lot Size House Mobile Home l/ Business _— Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ NO ❑
Specifications for System:
Auto Dish Washer YES ❑ NO ❑ "' %r
Auto Wash Machine YES ❑ NO -❑ v "~
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue
1 i 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.
Final Installation Diagram: System Installed by
r
Certificate of Completion 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.
JI
-
J__,,l
1 i 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.
Final Installation Diagram: System Installed by
r
Certificate of Completion 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. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requ
2. Address _—)
Home Phone
L TL, X,,,— , Business Phone 99 1- l a d
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, &.1 wrPf Sec/ FLot Nold
5. System used to serve what type facility: House Mobile Home ✓Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions Ay X 7 e
Bed Rooms-- Bath Rooms s- 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 -�
lavatory
dishwasher
urinals
showers
sinks �l
8. a) Type water supply: Public �� Private Community
b) Has the water supply system been approved? Yes_,t�No
9. a) Property Dimensions Alex is -v
garbage disposal
washing machine Z
b) Land area designated to- building site
c) Sewage Disposal Contractor eO,^ 'y A T _Z_
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.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD (6-82) ?J(
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