P7693 Gordon Dr "—I ""'.rK jY""` a'"v.'•r'c+,-.e s. v rii e ^.�:r v • -•y r N ,+^rya t, is _., , ..
T i
a DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article 111 of G.S.Cha t r 130a
/sanitary Sewage Systems,�f�^�c-f V-41 G ' �, Permit Number
fJamvG' ��� ` � 1�o Date., NO 7693
Location . 5 '" lef /)7 &✓
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home —T Business _— Industry
No. Bedrooms No. Baths — — No. in Family_ — Public Assembly Other`
Garbage Disposal YES ❑ NO Specifications for System:
Auto Dish Washer YES NO ❑
Auto Wash Ma^hine YES �] 0 ❑. o7V—�
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.
Potc�
`~
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 by39
ti " J'
� o VSsi
1)T 4
Ni
D
Certificate of Completion Date �r
\' "The signing of this certificate shall indicate that the system described above has been installed in cor�plidpce with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will1unction
j satisfactorily for any given period of time.
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE.OF COMPLETION
_,NOTE:issued in Compliance With Article 11 of G.S., Chapter 130a
_.Sanitary Sewage Systems, /^.�yrll�i� Permit Number
,:Na
_! sZQ i ���,.„�r,,_�/. Date:. w ` N2 Iz 6 9 3
Location ..,& /f /j '"' s��� 1 r�,;:;/ C2rf!
zf-Lf�l�r"l` -
Subdivision Name Lot No. Sec. or Block No. +-
Lot Size House Mobile Home _T Business _— Industry
No. Bedrooms ` No. Baths _ — No. in Family_ _ Public Assembly Other
Garbage Disposal YES p NO ;a-.*" Specifications for System:
Auto Dish"Washer YESNO
Auto Wash Ma^hine YES g p
O p "t� �
Type Water Supply d
'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.
l
3 _ EVEN
it
Improvements permit by
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:36,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 Qs �s`' 1)0,Zk�
Ill i \.
(n
r.d
F_ 11 1. ..,
- ate u
T�
Certificate of Completion • < C \� _ 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 guarantee that the system will function
satisfactorily for any given period of time. -
D
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION a
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME (01'1 rc[Al PHONE NUMBER
ADDRESS &��l 14,.1 /� �/tj"/ SUBDIVISION NAME
AZ LOT #
�
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED f
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED INFORMATION TAKEN BY 144
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
Rev.1193