316 Baltimore Rd ,�, � .-....�. ....,,.,��`o.�i;`'.`�s :'rc�r7t•t+.,p`7ry w�'fr.;,5`s rrN�'$'�'.�-'�^'�'+tl"upt'ta5+"d'i4"��''r7^^'��r.:�j;�s.e.Mratiw'X"+:.'1¢:uw..,�„i,:�+'+�.:ti:,.,..�.e.w. ,a�•�, , .t ... .. .
i 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
Name �— Date ` `� N2 7 f�74 2
Location sit,
Subdivision'Name o. Sec. or Block No.
Lot Size L elm House ✓ Mobile Home Business Industry
No. Bedrooms• No. Baths _ No.`in Family 2 _ Public Assembly Other
Garbage Disposal YES ❑ NO [t�%
Specifications for System:
Auto Dish Washer YES ❑
Auto Wash Ma^hine YES .Jp/'NO , t �bv
Type Water Supply
*This permit Void if sewage' ystem 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. n,
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.
Final Installation Diagram: System Installed_by -`�=��-��
D
1C)
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.
µsl �-...w+' ♦ t�' I i �/
IV
c.
DAVIE COUNTY HEALTH DEPARTMENTS\ Uo
t'
PERMIT AND CERTIFICATE OF COMPLETION
!r
IMPROVEMENTS
•NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage(S�ysteem_sq Permit Number
Name Date
Date
N-0
7 742
a cation �!�o \:D 1��i cti_z_ ►�.s � s x�. _ _ U
Lol
Subdivision Name ot1�o. Sec. or Block No
Lot Size ���' House 1/ Mobile Home _� Business Industry
No. Bedrooms � �° .No. Baths — No. in Family 2 Public Assembly Other
Garbage Disposal'•. YES ❑ NO [�f Specifications for, System: y �(
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. '
J •G' r
C ,
-- Improvemen IS 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:7046345985.
Final Installation Diagram: System.'Installed by
f r
• I
I
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 ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) 1\
NAME liz•ea `CMS W G Ez�h\i PHONE NUMBER 99'�'g `1q
ADDRESSJ I C� C�'(��\ a '�'� c� SUBDIVISION NAME
oc�S \>��\-o I `N '�• �� LOT #
DIRECTIONS TO SITE r �� `\ a 3 'Z�2�.o
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY 1-�6N',-�-- NUMBER BEDROOMS NUMBER PEOPLE SERVED 2
TYPE WATER SUPPLY W Z!�- SPECIFY PROBLEM OCCURRING ��z^• J'�
DATE REQUESTED 9 " D� " �I 4 INFORMATION TAKEN BY '�,-
This is to certify that the information provided is correct to the best of my knowledge,andthatII understand I am responsible for all charges Incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENTP-U "I
Rev.1/93