P4163 Carolyn BinkleyDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
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*NOTE: |Sougd inCompliance with G.Ei of North Carolina Chapter 130 ArUn|o 13n
Sewage Treatment d Disposal Rules (10NCAC10A .1934-.1968) Permit Number
NameDate 1163
Location
Subdivision Name
Lot No. Sec. or Block No.
Lot Size
House
Mobile Home __-_-_-_-Business -___----- Speculation --____-_
��
No. Bednoomn_____--_
No. Baths
No. in Fomi|y-=~Z_�'__
Garbage Disposal
YES [] NO
Specifications for System:
Auto Dish Washer
YES NO
E]
Auto Wash Machine
YES NO
Fj
Type Water Supply
*This permit Void if sewage system described below is not installed within 30 months from date of issue.
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Improvements permit bv /-
^Contauct a representative of the Davie County Health Department for final inspection of this oyobam 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 Dote ZZ
*The signing of this certificate shall indicate that the system described b 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
P. 0. BOX 665
MOCKSVILLE, NORTH CAROLINA 27028
(704) 634-5985
- DATE -/74
F
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DETACH AND MAIL WITH YOUR CHECK. YOUR CANCELLED CHECK IS YOUR RECEIPT.