248 Liberty Church Rd (2) w ,+.,rt�a t Hr..5 G.'�. .,�� � ,� '?. ...,. � .�t".�..f µ'a k^r.. ..`S.a S 4. - nv Z .w,,,.,;L:'� ,,•'-
Ql1- S' DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rues (10, NCAC 10A .1934-.1968) Permit Number
Name •� /�'�:�I• �/rA:c �/ .;,� w f �`7� _ Date " '� �A 41 .��i 4
Location
Subdivision Name Lot No. Sec. or Block No.
r.
Lot Size House Mobile Home � Business Speculation
No. Bedrooms '---F No. Baths No. in Family _
Garbage Disposal YES p NO [,a Specifications for System:
Auto Dish Washer -YES NO p
Auto Wash Machine YES NO p ��
Type Water Supply rr" __—
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Lit
/ 7
Improvements permit by
r
*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.
1
y y DAVIE COUNTY HEALTH DEPARTMENT
-IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment,and Disposal Rules.Q 0 NCAC 10A .1934-.1968) Permit Number
Name /�—/!�'j .� ,�3. ; �.� /l V .r Date
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home ��� Business Speculation
No. Bedrooms ---F No. Baths No. in Family _
Garbage Disposal YES E] NO 2-- Specifications for System:
Auto Dish Washer YES NO p
J /ter
Auto Wash Machine YES NO
Type Water Supply L4 _—
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
Lam-
1 ,
Improvements permit by —_
r
*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.
f
DAVIE COUNTY HEALTH DEPARTMENT
a"
_ IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name Date o2 — ° r� i
/ �,.,� f
Location _ _
,,Zmr, — ori
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _�Business Speculation
No. Bedrooms No. BathsNo. in Family _
Garbage Disposal YES ❑ NO p''�
Specifications ystem:
Auto Dish Washer YES E] NO ❑
Auto Wash Machine S e NO ❑ �
4
Type Water Supply __—
"This permit Void if sewage sys em described below is not installed within 36 months from date of issue.
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`
i
r 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 HEALTH DEPARTMiT
PERCOLATION TEST RESULTS
DATE
LOCATION
FINDINGS: HOLE PNO. CONME1NTS
Y//
By: l
LOT DIAGMVI
nn �/
V �
-05
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
P.O. BOX 57 X15
MOCKSVILLE, N.C. 27028
(704) 634-5985 4
STATEPEIJT FOR SEPTIC TANK IMPROVEME11TS PERMITS AND/OR SITE EVALUATIONS
'aNAPHE " DATE .I15� ✓ �1
ADDRESS PERMIT NO.
i
EXPLANATIOI4 OF CHARGE
AMOUNT DULa46, SANITARIAN„--i y
PLEASE REMIT THE ABOVE A14OUNT OF RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluations) can not be completed until payment is received.
Improvements Permit(s) can not be issued until payment is received.