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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 Number
Name /I � o?�?AS� pi�v,C Date N2 71-90
/ 6v s 27i
Location`�C/;
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home —vi 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 ❑ d ��
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 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 �� r
del
/a°
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.
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DAVIE COUNTY HEALTH DEPARTMENT
- -- IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOT_ E.Issued in.Compliance With Article II of G.S.Chapter 130a
z - /ySanitary//Sewage Systems ; / , Permit Number
-Name Date N2 71.90
l �..!! Jam. ����' I..�C`` �Yyr� .�L.. �1.--�-._„y��1 ! c'I r'/✓ � /'f /`� ✓ 1i✓//J-.°'"9' J�6'!/�L`"
Location
om
Subdivision Name -Lot-No_--- Sec. or Block No.
Lot Size ��/House� Mobile Home —4�_ Business Speculation
No. Bedrooms ` No. Baths No. in Family —
Garbage Disposal YES ❑ NO ❑ Sp cifications for System:
Auto Dish Washer YES ❑ NO ❑ _
Auto Wash Ma
YES,❑ NO ❑ �G� �.�1//y
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 permit by -- --
- i
'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
g V
f�
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.
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APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME_�de L,�-"9���io� - PHONENUMBER
ADDRESS %,S^ f�/`LU,`�, SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE V/Cali'i`f WeNel 4ZOo-
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY , NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY e& SPECIFY PROBLEM OCCURRING
DATE REQUESTED INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge,and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93