2203 Hwy 601S DAVIE COUNTY HEALTH DEPARTMENT
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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 (10 NCAC 10A .1934-.1968) Permit Number
Name � if 1J7�" Date °l „ .. r� _ :n il,320
Locationf /
Subdivision Name Lot No. Sec. or Block No.
Lot Size —( -- House Mobile Home Gam'` Business Speculation
No. Bedrooms c=� No. Baths
No. in Family
Garbage Disposal YES ❑ NO g— Specifications for System:
Auto Dish Washer YES ❑ NO
Auto Wash Machine YES Er-'NO ❑
Type Water Supply _
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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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: 704-63475985.
Final Installation Diagram: System Installed by (1791
Certificate of Completion
*The signing of this certificate shall indicate that the system described above has been installe 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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT 0-
Davie County Health Department,
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028n
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CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 0a� _ `�
1. Permit Requested By Business Phone
2. Address
3. Property Owner if Different than Above d SSS Fpm �1���7� A/Y) biQ
Address' �/ /� a 10 ell 0 U/—4 9_(: -
4. Permit To: a) InstallLefAlter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility. House Mobile Homer Business
Industry Other
b) Number of people -
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions °
Bed RoomsBath Rooms—Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes urinals garbage disposal
lavatory I showers washing machine
dishwasher sinks J
8. a) Type water supply: Public Private y' Community V,4_0 G,-\
'_a.a 7 -4-e'r,
b) Has the water supply system been approved? Yesy No
9. a) Property Dimensions
b) Land area designated to building site,
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
(9 O f ` o< 5 s 1 n+6 4r iv e. i
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DCHD(6-82)