161 Koontz Rd DAVIE COUNTY HEALTH DEPARTMENT o.G
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article II of G.S.Chanter 130a
Sanitary Sewage Systps Permit Number
Name Date � ! I ���' f J N� 4
_ - 5� _5
Location \)
Subdivision Name Lot No. Sec. or Block No.
Lot Size �� h �5p House Mobile Home — Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑, NO BQ Specifications for System:
Auto Dish Washer YES NO ❑
Auto Wash Machine YES N0 ❑ � lj �( , �y 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.
f
* Improvements permit by
*Contact a representative of the Davie County, HealthDepartment 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: 7047634-5985.
Final Installation Diagram: System Installed by Sa
\17a
r
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 COUNTYHEALTH DEPARTMENT •s' �" i�
U•
� IMPROVEMENTS PERMIT'°AND CERTIFICATE OF COMPLETION -
*NOTE:Issued in Compliance With Article II of G.S.Chanter 130a
Sanitary Sewage Systems Permit Number
Name `t .L Date ' ; c�' �' N2 5945
Location
y. �l
Subdivision Name Lot No. Sec. or Block No
Lot Size 'a o k I D;7 House Mobile Home — Business Speculation
r
No. Bedrooms No. Baths r No. in Family —
Garbage Disposal YES ❑ NO [gf Specifications for System: .�
Auto Dish Washer YES [ NO ❑ �- CJS'
Auto Wash Machine YES 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.
r "
S
, r
l
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 byar
t
1S
7A
r
Certificate of Completion ///y 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.
0.
WORKSHEET FOR SEPTIC SYSTEM REPAIR PERMIT
NAME C v���S �J 1 S PHONE NUMBER
ADDRESS IL ` K A SUBDIVISION NAME
\�e c,�
SUBDIVISION LOT#
DIRECTIONS TO SITE � �—
LA
DATE SYSTEM INSTALLED
NAME SYSTEM INSTALLED UNDER
SPECIFY PROBLEMS OCp4RkING
DATE REQUESTED _1� 9Q� INFORMATION TAKEN BY `'� -`"J