430 Bethel Church Rd DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF� COMPLETION
.NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
Sanitary S wage Systems S-8'� /��„��/f,P�/ Permit Number
Name` �D f ���'/91tJrrz�/� l,Y��^.� ,�ate /–�S N2 7841
Location /SPY” , ,r� '– pT1�X' e e�lt'w"i. —
Subdivision Name Lot No. Sec. or Block No.
Lot Size Y G House Mobile Home —Business -- Industry
No. Bedrooms ___o��.No. Baths— No. in FamilyPublic Assembl Other
�— Y �•
Garbage Disposal YES ❑ NO 2--' "r
Auto Dish Washer YES [�NO E] Specifications for System:
'/P0 04 ' e�
Auto Wash Ma thine YES p�NO E) � z0,
Type Water Supply
*This permit Void if sewage system escribed 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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Improvements permit by
*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 — 422;4!1
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.
. S S .r'2i•.° i'«r^M+4T"y*P�'`�.o3y �;-7`"'b'.c .. _ _ _ s ,� ..,
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DAVIE COUNTY HEALTH DEPARTMENT/
` IMPROVEMENTS PERMIT AND^CERTIFICATE OF� COMPLETION
*NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a
Sanitary S wage Systems Permit Number
Name 9��1,51,0C rZ cr''��ate /_S- T� N2 7841
Locations _F r� �f X P e i2UZ-12/ —
Subdivision Name Lot No. Sec. or Block No.
Lot Size� 'g C House Mobile Home _ Business _— Industry
No. Bedrooms .No. Baths --2,— No. in Family' Public Assembly Other ,;
Garbage Disposal YES ❑ NO Specifications for System:
Auto Dish Washer YES 2f"NO ❑ dad*/��,.
Auto Wash Ma,,hine YES �NO ❑ iY' ��
Type Water Supply _ __— ��S T' 1�a27 /
*This permit Void if sewage system escribed 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.
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.,
1:00-1:30 P.M.or 4:30-5:00 P.M.on day of completion.Telephone Number:704-6345985.
Final Installation Diagram: System Installed by �1irl/�i1
` f
Certificate of Completion —(("—�._.__ tate 1 u�
t.
*The signing of this certificate shall indicate thatrthe system described abov6 has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as;O,,guarantee that the system will function
satisfactorily for any given period of time.
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME �r�' ! / C��iDi7!/'�iC� PHONE NUMBER
ADDRESS 40r��� i� �`� SUBDIVISION NAME
W.&Ar t"`i If loge LOT #
DIRECTIONS TO SITE Aee' �O, 4 (_.. �y�C � 4�
DATE SYSTEM INSTALLED ? NAME SYSTEM INSTALLED UNDER
TYPE FACILITY .0 AV. NUMBER BEDROOMS a.f' : NUMBER PEOPLE SERVED
TYPE WATER SUPPLY 7 SPECIFY PROBLEM OCCURRING
DATE REQUESTED I-X-l f' INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge,and thjA understa I am respoi
sible f all charges incurred lf6m this application.
t, � r
SIGNATURE OF OWNER OR AUTHORIZED AGENT ff�ffl
Rev.1/93 e