176 Buck Seaford Rd (3) O A, Ko
DAVIE COUNTY HEALTH DEPARTMENT
_ IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems
` Permit Number
Name 1�11/ Date ' N° 809 6
:"
Locatior(✓r�?a 'v / . %' ��`J/s i/ /� T_��`'
Subdivision Name Lot No. Sec. or Block No.
Lot Size �r17�_ — House rMobile Home ---_ Business — Industry
No. Bedrooms c2 —.No. Baths No. in Family :�:2 — Public Assembly Other
Garbage Disposal YES ❑ NO ❑ '",
Specifications for System:
Auto Dish Washer YES ❑ NO ❑
Auto Wash Ma':hine YES p• NO ❑
Type Water Supply -- --- X?/J LIVZL
*This permit Void if sewage system descrtbeed.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.
wF'�t
Improvements permit by
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 —
19
pyr�
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.
DAVIE COUNTY 'HEALTH DEPARTMENT
r.
r� IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION !j
'NOTE Issued in Compliance With Article II of G.S.Chapter 130a f
Sanitary Sewage Systems
.. P"ei Its- umber
Name `'<-r',^: c?' --- Date '`' N2 8096, ,-,
Location',,
Subdivision Name Lot No. Sec. or Block No.
Lot Size / �ifl_ _ House — Z~'"� Mobile Home _—__ Business _ Industry
No. Bedrooms 2—.No. Baths No. in Family — Public Assembly Other
Garbage . sposal YES p N0 p Specifications for System.w'
:} Auto Dish Washer YES.,[ NO p
Auto Wash Ma-hive YES�6' fZ ❑ cno6't-3,'ex:,2
Type Water Supply
*This permit Void if sewage,syst eJCr below is not installed within 5 year-s ate�f-1 ue.
This permit is subject to revocation i si a plans or the intended use change '�"�� `�',
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS 'q
SYSTEM.
N$
- l
Imp rovements 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 —
Certificate of Completion = Date
'The signing'of this certificate shall indicate that the system described above has been' installed in compliance with
y y g in p NO way be taken as a guard tee.that the system will function
satisfactoaild for
hvenh eraiod of
-time. but shall in
..,v� regulation,
}
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME / PHONE NUMBER
17-1
ADDRESS SUBDIVISION NAME
LOT#
or
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED 1�9 NAME SYSTEM INSTALLED UNDER
TYPE FACILITY-,A/041:rf' NUMBER BEDROOMS 422 NUMBER PEOPLE SERVED
TYPE WATER SUPPLY a SPECIFY PROBLEM OCCURRING
DATE REQUESTED 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 for all charges Incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93