P3770 Jerry CouchDAVIE 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
Names ' , / �= i Date j 7 0
Location ,.. j _z/ -- '�'; +'. �i i. :;...:,
Subdivision Name Lot No. Sec. or Block No.
Lot SizeJ `v= f House Mobile Home Business Speculation
No. Bedrooms No. Baths No. in Family _
Garbage Disposal - YES NO [-}— Specifications for System:
Auto Dish Washer YES NO fl
Auto Wash Machine YES NO.
Type Water Supply
*This permit Void if sewage system described /befow is not ii staffed within 36 months from date of issue.
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Improvements permit by
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*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 byC�,,
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Certificate of Completion --�� �� ��- - D e 3 -S
*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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STATEMENT
DAVIE_ COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
210 HOSPITAL STREET
P. O. BOX 665
MOCKSVILLE, NORTH CAROLINA 27028
(704) 634-5985
DATE
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DETACH AND MAIL WITH YOUR CHECK.
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YOUR CANCELLED CHECK IS YOUR RECEIPT.
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BALANCE DUE -