136 Madison Rd a T,•- DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETI
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TE: Issued in Compliance with G.S. of North Carolina Cha
. NO ter 130 Article 13c v I
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Sewage Treatment and Disposal Rules (10 NCAC 10A .19''3,�4�-.1968) Permit Number
Name `f c� ��, 2�� Date _L0
Li — N2 O 3 33 5
Location �� o �� °c� ��\� 0U
nn - sem
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 0Specifications for_System:
Auto Dish Washer YES p�' NO J-]
Auto Wash Machine Y,E.S � NO
Type Water Supply
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
— — _J
h., 7
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 C��sL Date 1 v-
"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 Dfw?Aft_MENT e0t IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETI N
*r- OT
NE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c J�1,( I G
,Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name y e. Date NO S 3.`gyp 5-
Location
Location \C`
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 d. NO ❑ Specifications for System: �;
Auto Dish Washer YES p� NO
Auto Wash Machine YES d NO
Type Water Supply --
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
0
• L�1_ U
w �
re
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
f
Certificate of Completion2Date D
*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.
At
� INFATION FOR SEPTIC SYSTEM REPAIR PERMIT
�G
AME PHONE NUMBER
ADDRESS AD SUBDIVISION NAME
• D Sly/�� , G� �Q�-�
SUBDIVISION LOT #
DIRECTIONS TO SITE d
DATE SEPTIC SYSTEM INSTALLED (�
NAME SEPTIC SYSTEM ORIGINALLY INSTALLED UNDER )
SPECIFY PROBLEMS THAT ARE OCCURRING
22 71 re--
DATE REQUESTED/,&,-,& INFORMATION TAKEN BY