1091 Hwy 64W - I/X°
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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 Bi'11 Permit Number
Na i a .'-�O— Date N2 7886
tion
Subdivision Name Lot No. Sec. or Block No.
Lot Size -;f2l ( — House Mobile Home _--_ Business -- Industry
No. Bedrooms `-s --.No. Baths No. in Family Public Assembly Other
Garbage Disposal YES ❑ NO 8' Specifications for System:
Auto Dish Washer YES T NO ❑
Auto Wash Ma^hive YES NO ❑ V�JD.Y3 ,�'/ ���"'� �'s
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
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALUN
_,�4
SYSTEM.
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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: 704-634-5M.g7(op
Final Installation Diagram: System Installe y
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c�
Certificate of Completion — -- Date '2 _
'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.
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_- - - 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
NQft� l J/���'' — Date - N� 7886
l� S
Subdivision Name Lot No. Sec. or Block No.
Lot Size '� —' -- House Mobile Home ---_ Business -- Industry
No. Bedrooms Baths No. in Family — Public Assembly Other
Garbage Disposal YES ❑ NO i- Specifications for System:
Auto Dish Washer YES NO ❑
Auto Wash Ma^hine YES �j NO ❑ :,-
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
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLIN S
SYSTEM.
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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: 704-634-5985.1K7&0
Final Installation Diagram: System Installe
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L-7
Certificate of Completion --�L _— 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
�, 4 satisfactorily for any grv_enperladof time.
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
/APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME �x�71 -Tllyl _ PHONE NUMBER61
ADDRESS �D9� C��S //� ��`�. SUBDIVISION NAME
LOT#
DIRECTIONS TO SITE ��/• �Lr�- B"�--
%►
DATE SYSTEM INSTALLED� Q�NAME SYSTEM INSTALLED UNDER Wa-zo�
TYPE FACILITY
TYPE WATER SUPPLY NUMBER BEDROOMS NUMBER PEOPLE SERVED 7
SPECIFY PROBLEM OCCURRING d
�Iy��.
DATE REQUESTED oC'�O " / INFORMATI TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge,a that I understand I am esponsible r all charges Incurredm this appllii ttionn..
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93