P6682 Hampton Ln �' x• =a - wti>� DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND .CERTIFICATE OF COMPLETION
*NOTEAssued in Compliance With Article I I of G.S.Chapter 130a
SlanitarySewage S stems Permit Number
Date X�� NO
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Locati •^'�/ ��� /f/./�` 1 r' I`� e1 /i�',�/�! !P }�/�r (.. v _� F/ �. ��
Subdivision Name / Lot No. Sec. or Block No.
Lot Size ,117 House lam` Mobile Home _______ Business Speculation
No. Bedrooms - 7:�' No. Baths Z No. in Family —
Garbage Disposal YES ❑ NO p'' Specifications for System:
Auto Dish Washer YES p NO ❑ :,
Auto Wash Ma,hive YES m NO ❑
Type .Water Supply ✓ "� --- �.-�5'�iir. i,%✓
*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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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. or 1:00-1:30 P.M. on day of completion. Telephone Number 704-634-5985.
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Final Installation Diagram: System Installed by t. ► �ar�
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Certificate of Completion date A
.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.
' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section p2
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By 2 'o TTrs >y Il.f) Fdz5 /UL.
Mailing Address T Q, 8a:J! �] 5r' — c4 V A til LE , N. C- 2700 �o
Home Phone q8— 'EF yt Business Phone Cl,'8`3 9-146
2. Name on Permit if Different than Above
3. Application/Permit for: ❑ General Evaluation PSeptic Tank Installation
4. System to Serve: &House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot#
❑ Basement/Plumbing
No. of People 3 ❑ Basement/No Plumbing
No. of Bedrooms 3 93-Washing Machine
No. of Bathrooms I I F� ; . ❑ Dishwasher
Dwelling Dimensions 3 6' 2 ❑ Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
9: Type of water supply: ❑ Public ❑ Private ❑ Community
8. Property Dimensions Sewage Disposal Contractor
�. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes P- Ilio
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property:
a
This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurred from this application.
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DATE VSIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
DCHD(12.90)