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_,f "' DAVIE COUNTY HEALTH DEPARTMENT
t IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION:'
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
- Sanitary Sewage Systems Permit 1�N/umber
Name _Y� Date - �. ` N� 7 4 4 Q
J ' �^V V � U�!"'n'' \ \ V.� �1•t��/v� -•'i-' \ J W� � \l N\Ytil ��♦ a
Subdivi3ion Name Lot No. Sec. or Block No.
Lot SizeHouse Mobile Home _T Business Industry
No. Bedrooms NP.�Baths-`��' No. in Family __ Public Assembly Other
Garbage Disposal YES ❑ NO-2 t '
4., ,Specifications for System:
Auto Dish Washer ' , YES.,p NO, p'
Auto Wash Ma shine 'YES NO,(' csr,
.Type Water Supply
k*This permit Void if sewage system described betow is not installed within 5 years from date of iss e.
�This'permit is subject to revocation if site plans or the intended use Change.
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Improvements permit by� 1:1 �-
*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.i r 4:30-5:00 P.M.on day of completion.Telephone Number:704-634-5985.
Final Installation Diagram: System Installed by
�,01 '
I eroLO3�
4 �sP
Certificate of Completion �'i 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 a guarantee that the system will function
satisfactorily for any given period of time.
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) 1( pp
NAME F.��- c� '�- PHONE NUMBER_
ADDRESS V 'y o�j S7L� SUBDIVISION NAME
o N\ .1 1� �-� LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED �� NAME SYSTEM INSTALLED UNDER
TYPE FACILITY �-10y se NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY �9`- 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 0\'
Rev.1/93