111 Jolley Rd A A",
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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 Number
Name XZ?4:4c �,WLYZ Date N2 634 '
Location Z,
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home -- Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES [3 NO E] Specifications for System:
Auto Dish Washer. YES [P NO ❑
Auto Wash Maohine YES [f] NO E] V
Type Water Supply
*Thispermit Void if sewage system described below is not installed within 5 years from date of issue.
This.i permit is subject to revocation if site plans or the intended use change.
a x sv-V
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
Certificate of Completion 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 HEALTH DEPARTMENT VP
IMPROVEMENTS PERMIT AND .CERTIFICATE OF COMPLETION 1'
*NOTE:')ssued in Compliance With Article I I of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number Number
Name ' '� -,'s� , }.-i� '> - Date �''+'�'/_ r� N2 U.. 34-3.
.
Location /o /' Jly
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile-Home Business Speculation
No. Bedrooms No. Baths -No. in Family %
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer, YES NO M
Auto Wash Ma.hive YES NO ❑ �. 's X/ b j
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.
f
,
Improvements permit by
*Contact a representative of the DavieCounty 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 `l�/-�•l�� y }�"
Certificate of Completion z 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.