634 Boxwood Church Rd DAVIE .COUNTY' ,HEALTH ;DEPARTMENT
r IMPROVEMENTS PERMIT AND `CERTIFICATE OF COMPLETION
f it NOTE ,Issued in.Compliance with`G.S. of. North Carolina Chapter.•130 Article 13c
:Sewage-Treatment
–and Disposal_Rule- (10,NGAC 10A .•1934-,1968) -`. .,, :Pe mit Numbed
VV
„Name 1>ILrv�'rr. F _ n Date
ev
,Location s'G/. e r-- C i '�'�t•/ C,! /a� � �'"r' i'�r'�' C�� �4 ,i''> �.
lir ;- •. <' , - _ - .. •
I� ,Subdivision Name Lot No... Sec. or Block No:
I Lot Size House " Mobile Home _.Business Speculation
No. Bedrooms: 3 No. BE "_ �' No. in,Family
{
i� 'Garbage Disposal YES ❑- ,NO ❑, Specifications, for; System:
p' Auto.Dish Washer. YES p NO 0.
'i Auto Wash.Machine -YES ❑,. NO �:s— h ' r`� ✓ ''
6
;!Type-Water Supply. ---
"ll "This.permit Void if §ewage.sysfem "e�gibed below.isnot installed within 36:months.from date..of issue.
-
!1 'i" ; ,.• .. .� � Imp 'ae ents permit by
'Contact a'representatiVe of the Davie County.Healtk Dep ent r final inspection -of this- system between 8:30 Y.
i 9:30 A.M. 1:00-1:30:,P.M. on day of completion._Tele h ne u ber: 704-634-5985.
fr Final.Installation Diagram: t 5,a•Installed by �.a� fi
1, i� V' '� ./ / / • t
� ' — , i� —.•s�_..i...--�---._ter- .—. - ..
li
1 Certificate of Completion P Date.
:.
` #The signing of this'oertificateshall indicate that the system described above.,has' been installed in compliance with
the standards set,forth in the above regulation, but shall in W way be taken as a guarantee that the system will functi n
satisfactorily.for.any given period of•time. . ;
INFORMATION FOR SEPTIC SYSTEM REPAIR PERMIT
NAME PHONE PHONE NUMBER
ADDRESS / 1 d , 73 6 SUBDIVISION NAME
QS 70d SUBDIVISION LOT #
r DIRECTIONS TO SITE
8-�--
_ %v
DATE SEPTIC SYSTEM INSTALLED
NAME SEPTIC SYSTEM ORIGINALLY INSTALLED UNDER
SPEC FY PROBLEMS
OQBQLEMS THAT ARE OC URR;NG
0-
DATE REQUESTED -f�� INFORMATION TAKEN BY-2 )