P3352 Granada DriveDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
_*N�C)TE: 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 !�2r. 33 152
Location
Q,4A on cNo.
k -f "A -1-11 - IT k--� u ----
Subdivision Name Lot No. Sec. or Block No.
Lot Size i�Z, House Mobile Home Business -- Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES NO 1�1— 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.
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 6,'�
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.
,q ^)
APPLICATI TION/ IMPROVEMENTS PERMIT
ounty Heal
lqr 1 ,
ty Health Department
vironmental Health Section
.. R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
es,
Home Phone
1. Permit Requested By 4� -Business Phone
2. Address — IZZ;Z gZ,2Z,!� Z �& 4,��a /1 2 oZ
3. Property Owner if Different than Above' --I
Address
4. Permit To: a) Install;X, Alter Repair
b) Privy— Conventional— Other Type—
Ground Absorption
c) Sub -Division Sec.— Lot N _�7_
5. System used to serve what type facility: House— Mobile Homepu iness
Industry— Other
b) Number of people c2gf!�:
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions– Z
Bed Rooms Bath Rooms I Den w/Closetija-1,49
b) If Business, Industry or Other, State: Number of persons served
What type business, etc. 4
Estimate amount of waste daily (24 hours)
7. Number and type of water -using fixtures:
commodes urinals
garbage disposal
lavatory showers washing machine
dishwasher
sinks
8. a) Type water supply: Public Private— Community
b) Has the water supply system been approved? Yes— No
9. a) Property Dimensions I I ?_�– ex A
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.
7- ;�2
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
� A �u -, jv- 1 4
DCHD (6-82)