151 Green Grass Rd DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION - a 0�
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a �''bU
Sanitary Sewage Systems ,✓ Permit (Nu7mber
Name. � � ° `�' �` Q•\�N h Date l�_9a N2 7977
17
Location ` s
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home —_— Business —_ Industry
No. Bedrooms —.No. Baths --L— No. in Family Public Assembly Other
Garbage Disposal YES ❑ NO IR/ h
Specifications for System:
Auto Dish Washer YES p NO
Auto Wash Ma.hine YES NO ❑ �/ r► �,�
Type Water ,Supply _ �_� - ---- — , / 3 C/
*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 CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS • ,,;_.
SYSTEM. r' -
L-7-7
T
Improvements permit by �`s� LID 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:704-634-59985'.
Final Installation Diagram: System Installed by _ "5A
N s .�.
-9 5"
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.
0
DAVIE COUNTY HEALTH DEPARTMENT fi
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION o. off`
�•NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems Permit
7 Number
Name `ti,�.. '�r r� o L.\: �,: �` —Date J -� N2 19 7
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House - Mobile Home ---_ Business -- Industry
No. Bedrooms ci —.No. Baths --L— No. in Family — Public Assembly Other""'
Garbage',Disposal YES ❑ NO M/
Specifications for System:
Auto Dish Washer YES ❑ NO p� D
Auto Wash Ma^hine YES j-'NO ❑
1- �
\ J
Type Water Supply f
'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 CONTRACTOR MUST SEE THIS PERMITILAYOUT BEFORE INSTALLING THIS
SYSTEM.
Ef 1)
:y,;
' Improvements permit by
*Cont act 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: 704-634-598`5.
Final Installation Diagram: System Installed by
F
Certificate of Completion
`— �- Date S
'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.
F�
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME 9a-4' Aa,1�4-J212�) PHONE NUMBER sp aZI�pp�lT
ADDRESS � / /LP� � - SUBDIVISION NAME
C140CIG�1�= LOT #
DIRECTIONS TO SITE /ads • �9� ��-' /•yGil� �- L�_g7^'sv
DATE SYSTEM INSTALLED J57t "ME SYSTEM INSTALLED UNDER
TYPE FACILITY -4''`_NUMBER BEDROOMS NUMBER PEOPLE SERVED
' o°Z
TYPE WATER SUPPLY � SPECIFY PROBLEM OCCURRING ��✓� =a� �e ' 7�
.DATE REQUESTED "�02'I� INFORMATION TAKEN BY �&/_p
This is to certify that the information provided is correct to the best of my knowledge,and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT ezza
Rev.1193 r