284 Red Fern Ln DAVIE:;COUNTY,HEALTH 'DEPARTMENT
'- -IMPM VEMENTS PERMIT AND'CERTIFICATE OF COMPLETION
`NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
Sem
;rj.tary S wa e s s Permit Number
Name— �`f 1 p2 ,-�' Sof,i" Datek - l� No 5917
Location Vii?/. /,''Yy�r<
Subdivision Name Lot No. Sec.or Block No
t .
Lot Size _, House Mobile Home_ Business--Speculation
No. Bedrooms _No. Baths /2 No. in Family _
Garbage Disposal YES ❑ NO l Specifications for System:
Auto Dish Washer YES 4 NO ❑
Auto Wash Machine YES LTJ NO ❑ lis
Type Water Supply
'This permit Void if sewage system described bejow is of installed within 5 years from date of issue.
This permit is subject to revocation if site plans a the i tended use change.
i
P
Improvements permit by f e' '
'Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number:704-634-5985.
Final Installation Diagram: System Installed by
r'
f
r A_
Certificate of omp on _Date
"The signing this certificate shall indicate that.,the-system--described••above has been installed in compliance with
the standar 'set forth in tie abov0 r w ation,`but shall in NO way ba taken as a guarantee that the system will function
satisfactorily for any given period of tKej ���'�
L
DAVIE COUNTY HEALTH DEPARTMENT
s Y =' IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
-*NbjE:Issued in Compliance With Article 11 of G.S.Chapter 130°
Sanitary Sewage Sys ems Permit Number
10, 1Name -,�T ,t�,/ ✓ fs (% R%t ;lf/ Date �X- =2
N2 590
Location
rJ J
Subdivision Name Lot No, Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation '
No. Bedrooms _ No. Baths _ No. in Family 42 _
Garbage Disposal YES ❑ NO
Specifications for System:
Auto,Dish Washer ,• YES NO ❑
Auto Wash Machine YES T
NO ❑ ! `� '`� '��' �
Type Water Supply =7a0 JT1(10?
*This permit Void if sewage system described bejow is�iot installed within 5 years from date of issue.
This permit is subject to revocation if site plans a the'ihtended use change.
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. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by t-'-�
i p a
( erti ica e of Corr pletion \ `�� � Date'The signing o_trtificate shall indicate that.°,the-system-described-above has been installed in compliance with
the standards set forth in the above"r�.rt�_- °tion, but shall in NO way b tdken as a guarantee that the system will function
satisfactorily for any given period o�thf� _��
J
, • APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
_ Davie County Health Department
Environmental Health Section
P. 0. Box 665 ��ctVE
Mockaville, NC 27028
1 . Application/Permit Requested By 6 �0- 9-S T
e
Mailing Address / //M dEX v/N 0Ivs7 ee, Z"It �('�e�wt//� /✓C��a�>3�
Home Phone n77/ 37e09 Business Phones ,-.279 76
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For: General Evaluation D/S/Tank Installation
5. System to Serve: douse Mobile Home 0 Business
Industryu Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
i
No. of People 19, Dwelling Dimensions /X'F/
No. of Bedrooms Basement/Plumbing
No. of Bathrooms asement/No Plumbing
ashing Machine ishwasher 0 Garbage Disposal
7. If business, industry, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers
S. Type of water supply: 0 Public 5--�r ivate Community
9. Property Dimensions AAeRtX 36 AORES
10. Sewage Disposal Contractor SEPllC 7-AdX- 06. S��is t.P�
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes 8-190
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of 5
years from date issued. Improvements Permits are subject
to revocation, if site plans or the intended use change.
Effective October 1, 1989.
This is to certify that the information provided is correct to the
best of my knowledge, and I understand I am responsible for all
charges 17 incurred from this application.
r 9� �j-
Date Signature
Directions to Property :
661
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DCHD (10-89)