910 Ijames Church Rd .a ,..., :.,- ...s' ..-:. r�..s+—v._,x-r>y-�••_ .t.--�«:.-r-y.-.-�.-�. _ 'Ma M r+"..r-.�_.w-.e= .-Y:-t�..,.
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
Sanitary Sewage Systems Permit NOmber
Name�z/� c� �i � l pate � 1
/v,'/ C N2 y0.43
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Sized House Mobile Home l/� Business -- Speculation
No. Bedrooms —E2 No. Baths No. in Family
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑
Auto Wash Ma^Bine YES ❑ NO ❑ ���V ��✓r�L�/
Type Water Supply --- ZGnr /I
*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 orthe intended use change.
per Ll
�9- I
OJ
r
Improvements permit by
*Contact a representative of the Davie County Health Department for finalin ection of t ' system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number 704 634-5985�Yy�
--�
c
Final Installation Diagram: System Installe by —
m rn �
Certificate of Completion \ C –�\ Date �3 -10- 93
*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 penod of time.
7
'.� `'''} DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION '
*NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a
`Sanitary Sewage Systems Permit umber
NameG �"/y'� G -r'� r�` .��>it. ,Date `'� � ���J% Np
143
Location �,d
Subdivision Na�m-e� Lot No. Sec. or Block No.
Lot Size �'�+'' House Mobile Home 1� Business -- Speculation
No. Bedrooms .No. Baths No. in Family
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑
Auto Wash Ma.hine YES ❑ NO ❑ Gl/i^ ,.�. �,
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.
Improvements perm4y -- —
�,tContact a representative of the Davie County Health Department for final inspection of�t, ystem between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number 7g4i634-5985,,
Final Instal lation.,Dig ra System Installed b
I
j
ti l�
I-t o
f
p!
Ot " n' l atf of CompletioV'.
\ � \ Date J
"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)
NAMEQi�i�>� /%s�/'C�('�� PHONE NUMBER
ADDRESS� '�'!�''/ SUBDIVISION NAME
0'/1 /l LOT#
DIRECTIONS TO SITE 2.we� Q es �/
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY .4-& NUMBER BEDROOMS =-2 NUMBER PEOPLE SERVED /
TYPE WATER SUPPLY :•t/Z,% SPECIFY PROBLEM OCCURRING��f).�
L l�
DATE REQUESTED INFORMATION 9� INFORMATION TAKEN BY
This is to car*that the information provided is correct to the best of my knowledge,and/that I understand I am responsible for all harge.,npirred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT-Z' w ' //V li�-�y
Rev.1193