353 Fork Bixby Rd (3) / DAVIE COUNTY HEALTH DEPARTMENT
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IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
Name 1 z {, :�fifi r'i%/ �r,j-i (I r: �/ `:f —�/ �1�i,Date 1-^Y�s1 c'��J N2
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Location '� �
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Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home . ' Business __ Speculation
No. Bedrooms –`%� No. Baths 1 _ No. in Family
Garbage Disposal YES ❑ NO C1 Specifications for System:
Auto Dish Washer YES p NO ❑
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Auto Wash Ma thine YES � NO ❑ >
OrType Water Supply
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if siteplans or the intended use change.
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Improvements permit by — 1
*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_�- r n ,A ;" ° "' °*?'– •-
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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.