3190 Hwy 601SG
DAVIE COUNTY HEALTH DEPARTMENT
- `IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
sanita-ry sewage/ Systems Permit Number
Name P r/���/l�Gr/C7lD/_f_ Date N2 8045
Location ��/�
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Subdivision Name Lot No. Sec. or Block No.
Lot Size Zren `_C - House Mobile Home Business __ Industry
No. Bedrooms .2 —.No. Baths _ 2 _ No. in Family -� _ Public Assembly Other
Garbage Disposal YES NO ❑ Specifications for System:
Auto Dish Washer YES NO p ZC
Auto Wash Ma^hine YES NO [) 9
Type 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 site plans or the intended,use change
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ATTENTION: YOUR SEPTIC SYSTEM CONTRACTO UST SEE THIS PERMIT/LAAYOUTEFOR,E INSTALLING THIS
SYSTEM.
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Improvements permit b
Y
`Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M.,
1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by _
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Certitic _Date 1,3
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'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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DAVIE COUNTY HEALTH DEPARTMENT l t�
*NPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION '.
'NOTENra ud n Compliance With Article 11 of G.S. Chapter 1306 • ` '
Sanita ySewage Systems Permit Number
P,20 Date
N2
8045
Subdivision Name Lot No. Sec. or Block No,
Lot Size fC� House — �� Mobile Home _--- Business _— Industry
No. Bedrooms— No. Baths-- No. in Family -� — Public Assembly Other
Garbage Disposal %YES'ID NO p Specifications for System:
Auto Dish Washer YES NO p
Auto Wash Ma^hine YES NO []
Type. 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 site plans or the intended use change
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTO UST SEE THIS PERMIT/LAYOUT.BEFORE`INSTALLING THIS-`,,
SYSTEM.
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Improv@ en�tLpi rmit by{_'71
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'Contact a representative of the Davie County Health Depaartment,for final inspection of this'*y tem between 66-9:30 A.M.,
1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number 704-634-598
7 �. 1
Final Installation Diagram: SystemI s tled by
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Certific. — -- 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.
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DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME � DG 1044- ,'zo PHONE NUMBER ��� GSA
ADDRESS_l�U �'D1S SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE 1pO` i �i9��•�'il�-e,�"
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS_2 NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED �S"1�(INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible fc fall charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT,
Rev. 1193