P2783 CooleemeeM DAVIE COUNTY "HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note:, Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
;Permit Number
Name C C 4-yrL,ka ra Date
Location (cn) �` c
Subdivision Name Lot No. Sec. or Block No.
Lot Size I -r' x 6, 3 House Mobile Home`'' Business Speculation
No. Bedrooms Z- No. Baths f No. in Family 2—
Garbage Disposal YES ❑ NO p-- Specifications, for System: 2vo1
Auto Dish Washer YES ❑ NO E] -
Auto Wash Machine YES ❑ NO ,0 i
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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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-elvj—
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• Certificate of Completion c� e I ��%� Date � 71,91
*The signing of this certificate shall indicate that the system described above has been instglled 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.
DAVIT COUNTY HEALTH DEPART IE IT
ENVIROBIMETAL HEALTH SECTION
SOIL/SITE EVALUATIOV
DATE
ADDRESS
Cuy�Y _ LOCATIOt? P
LOT SIZE UrD
TOPOGRAPHY:
SOIL TE,,TURE : PZ
SOIL STRUCTU r, : 44)-4
DEPTH: vldPso:C - vu c�P,aryl.
RESTRICTIVE HORIZOUS: sA�,P,���' of y/'
PERCOLATIOII PATE: Presoak liark &
2.
3.
Pate
***CLASSIFICATIOI?:Sui,table Provisionally Suitable Unsuitable
C01PHEITTS:
SAT?ITARIAIT
f1TTT TT.11f�1111.• i
s, STATEMENT
DAVIECOUrM HEALTH DEPARTMENT
�•`.• `
s 80,3 HOSPITAL STREET
K,0- BOX 865
MOCKSVILLE, NORTH, CAROLINA 27028 '
(704) 83"985
r
DATE
L,r
DETACH AND MAIL WITH YOUR CHECK..: YOUR CANCELLED CHECK IS YOUR RECEIPT.
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p� w.
FORM F082 Available from GRAYARC CO., INC., Brooklyn, NY 11232