P3165 Ricky DullDAVIE 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 - ':— Date
Location f �t�t a• ;% =;. "i,' �_
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 Q 'NO E]---' Specifications for System: .
Auto Dish Washer YES [] NO
Auto Wash Machine YES p NO Q L -
Type Water Supply i
*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
Certificate of Completion Date X,
*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.
i DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*N te: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
`.• Permit Number
Name �-� / % �`� Date
Location'" % /- % ;f %_ -t //, ✓
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,p' Specifications for System:
Auto Dish Washer YES ❑ NO fl
Auto Wash Machine YES (❑ NO C] ,
Type Water Supply
X
*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���/�"
w
.,4
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.
STATEMENT
DAVIE COUNTY HEALTH DEPARTMENT
' ENVIRONMENTAL HEALTH SECTION
210 HOSPITAL STREET
s P. O. BOX 665
MOCKSVILLE, NORTH CAROLINA 27028
(704) 634-5985 �
DATE o�o6io / l
L
DETACH AND MAIL WITH YOUR CHECK. YOUR CANCELLED CHECK IS YOUR RECEIPT.
BALANCE DUE -