296 Cedar Grove Church Rd 'Y cvti Tr �' ,Y.awr'D''o+.'41y;M r" ftd'•Y�r">.f`°"" 'rF"y yrvtiq i•``.`i,+.,"*'tlt'P``,'Y�';. �}�'i+#.,t{ '�:S�l i�i�� .9 9VW,1fiIi*.,.y" 'Sys., 'r., .+ r .�a yir.A�'Y ,�+!%'.r'r k�•i
1,.4 1�i i S
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DAVIE COUNTY HEALTH DEPARTMENT
_ IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION. J O
j *NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary.Sewage Systems l Permit Number
Name 'i Q N tJ e\� 1 Z o _ Date 7436 N2 f 4 3 D
Location _ o c"15-14���p \v ,�° • 16 ,� ;
UM 4Y�
(��F tom - 15. Cs� b i ds AN 1�► ,��'ti .
Subdivision rNra�me o. Sec. or Block No.
Lot Size��''�" Houses 'Mobile Home — Busi' Industry
,s
No. Bedrooms `-.:No. Baths -' � No. in Family `� � Public Assembly Other
Garbage Disposal YES p NO a�
Specificafions for System:
Auto Dish Washer' YES NO `'
Auto Wash Ma^hine A"' YES a,'NO p 22 t'„
Type Water Supply ?J o O x �" �->n
*This permit Void if sewage sypt.em 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., 4Ju
Lt
Ev c a dao '
i:J 6r� l bu "'
✓kvt' 6a
Improvements permit by ._---_—`�f•
*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 l; �
-� �,
Certificate of Completion >�-�� Date
'The signing of this certificate shall indicate that the system described above has been installedincompliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
r satisfactorily far_anyy�given period of time. f -
... � �r.,t l YH.- , 4A a 5 °dei.""i\ • I- .. is C... .. . ,i t. _ ..
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DAVIE COUNTY HEALTH DEPARTMENT ,_
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION• 3
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewag.�e..Systems Permi
t Number
--,Name �`' N e \�� `�` o �Y `N Date - �j N2 ! 4 3 6
Location
.. - h`. 1=\ \� \'J..'"�'•...�.T+ .a�'.:,�W�_L3kti, \�V``\\ � `>•C N-_751 CS's. - _..7::3�.1 �.)`•��)\� .,
Subdivision Name -- -- —Lot-N&. Sec. or Block No.
x
Lot Size 10 House Mobile Home _T Business Industry
No. Bedrooms f-' No. Baths —1-- No. in Family _ Public Assembly Other
Garbage Disposal YES ❑ NO [ja/ Specifications for System:
Auto Dish Washer YES [ NO p ,
Auto Wash Ma shine YES E!K NO ❑
Type Water Supply ci •�� 3 v u X s
'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. r �,
T dIJ
bu
VvEr� bti 1
Improvements permit byQu�- - ;
*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 < it� —
L Ay
Certificate of Completion >� Date
'The signing of this certific to shall indicate that the system described above-has been}instal led in compliance with
if '--�Zhe standards set forth in thgabove regulation, but shall in N(D.way be taken ad'a'guarantee that the'`system will function _
satisfactorily for anygiven pefiod of time.-
-
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DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
ir APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME L& %A� R w N PHONE NUMBER 9 9" ' q E6 LI
ADDRESS aa� SUBDIVISION NAME
C-)C- LOT #
DIRECTIONS TO SITE Ll I=
DATE SYSTEM INSTALLED I S NAME SYSTEM INSTALLED UNDER
TYPE FACILITY \\6 O se NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLYo Nft* SPECIFY PROBLEM OCCURRINGs - h-fJ - d1iQ >,
DATE REQUESTED -�`�- INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge.and that I un,derstand I err►responsible for all chargee ncurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1193