P4130 Robert Koenach.DAVIE 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
Name
J. -�,' Date ! a11.r
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 p-- Specifications for System:
Auto Dish Washer YES [a NO p
Auto Wash Machine YES NO p
Type Water Supply
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
*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
'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 tkh'�'9� _f':,function
satisfactorily for any given period of time.
STATEMENT
DAVIE COUNTY HEALTH DEPARTMENT
or ENVIRONMENTAL HEALTH SECTION
210 HOSPITAL STREET
P. 0. BOX 665
MOCKSVILLE, NORTH CAROLINA 27028
(704) 634-5985
G�P�I✓ ��rfi�C%'�
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DETACH AND MAIL WITH YOUR CHECK.
DATE
-I
J
YOUR CANCELLED CHECK IS YOUR RECEIPT.
STATEMENT
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
210 HOSPITAL STREET
P. 0. BOX 665
MOCKSVILLE, NORTH CAROLINA 27028
(704) 634-5985
DATE Second Notice
4/7/86
Mr. Robert Koenach
• Route 1, Box 112-B
Advance, NC 27006
L I
DETACH AND MAIL WITH YOUR CHECK. YOUR CANCELLED CHECK IS YOUR RECEIPT.
2-5-85 1 Revair Permit #4130 125.00
BALANCE DUE —