P2926 Charles PottsDAVIE 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
Named/f all
5 Date—.'
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:
Auto Dish Washer YES O NO ❑
c_
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 _\Jrt
5-4.4-.2-
L; n c .0 2. aye : s: (/1-
Certificate
Lr
Certificate of Completion Date
"The signing of this certificate shall indicate that the system descri d 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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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 _\Jrt
5-4.4-.2-
L; n c .0 2. aye : s: (/1-
Certificate
Lr
Certificate of Completion Date
"The signing of this certificate shall indicate that the system descri d 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.
DAVIE COUNTY HEALTH DEPARTMENT `+rr
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c. �-'-
�. Permit Number
Name -- Date
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms No. Baths No. in Family 1
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.
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 1), I k'� 1 n -' C;..L-,-
2 77A! S: <! f
0
Certificate of Completion �� l� <� Date
*The signing of this certificate shall indicate that the system descri ed 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.
\ 1
e�
l
1
1
t
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 1), I k'� 1 n -' C;..L-,-
2 77A! S: <! f
0
Certificate of Completion �� l� <� Date
*The signing of this certificate shall indicate that the system descri ed 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.
STATEMENT . ,
11 L1
' DAVIE COUL1 DEL !\
,`IlEALTH•
r
8f10OSPITAL STREET
.; . • 1 •' .
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•O. BOX 865
MOCKSVILI ; NORTH- CARpUN" ',` X7028
PQ 634-M
DATE�/�
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DETACH AND MAIL WITH YOUR CHECK.' `1' YOUR G`ANCELLED CHECK IS YOUR RECEIPT: ?
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FORM F082 Available from GRAYARC CO., INC., Brooklyn, NY 11232