262 McKnight Rd �1p..+ ..• `7+°:� "vri �'#�Li#vf t'-rid' Ly' ti�`�i '.i:�.(,' - .. i.;
.r.r � f '!(,. �"i•;Y � �M s 'T�R .>.y,�,v•.3r.at'hv �...o{�. tse.;ai•:
DAVIE COUNTY HEALTH DEPARTMENT
I IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION j
*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a '
tary Sewage SygemsPermit Number
Name .�� �� E R _ Date �T y ' y N2 t T
Location �'S 04 !Pj at 9
al, Jl�
Subdivision Name Lot No. Sec. or Block No.
f
Lot Size o,'L ?H�aue Mobile Home _ Business _— Industry
No. Bedrooms No. Baths .2 No.'in,Family Public Assembly Other
Garbage Disposal,. YES ❑ NO p�
Specifications for System:
Auto Dish Washer YESy NO p
Auto Wash Ma shine YES 2 'NO p ? 3" . /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 subjept to revocation if site plaids or the intended use change.
VVI ,
i
'1
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.,
1:00-1:30 P.M.or 4:30-5:00 P.M.on day of completion.Telephone Number:704634-5985.
Final Installation Diagram: System Installed by \JQ
S 1
14
f
Certificate of Completion - Date �» i
'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 Mime.
�- �� �J_� �, S, :r ter, i 0 •�D �`
DAVIE COUNT'S HEALTH DEPARTMENT
IM
ROVEMIENTS PERMIT AND CERTIFICATE OF COMPLETION f �-
"NOTE:Issued In Compliance With�4rticle II of G.S.Chapter 130a
Permit it Numb
ery Vage SyLi yName �%AA
- V\• Date N° 741_0
Locationb
-k —
Subdivision Name Lot No. Sec. or Block No.
Lot Size Hbuse Mobile Home _ Business Industry
No. Bedrooms ; !No. Baths No. in Family Public Assembly Other
Garbage Disposal YES (D NO Ig/ Specifications for System:
Auto Dish;Washer .. YES NOr-� ��
Auto Wash Ma thine YES E3� NO p
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.
yti f J
FENS�' F
i
Improvements permit by
*Contact a representative of the Davie County Health Depprtment for final Inspection of this system between 8:30-9:30 A.M.,
1:00-1:30 P.M.or 4:30-5:00 P.M.on day of completion.Telephone Number:704-634-5985.
Final Installation Diagram: System Installed by
S 1
{
t.
r` Certificate of Completion 1Z Date )I _'v1 ZA 14
'The signing of this certificate shalf—ndicate 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 al a guarantee that the system will function
satisfactorily for any given period of time.
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
• APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME PHONE NUMBER
ADDRESS R+ C� ou 4 SUBDIVISION NAME
LOT#
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED 1 NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS `� NUMBER PEOPLE SERVED
TYPE WATER SUPPLY Cy �, SPECIFY PROBLEM OCCURRING
DATE REQUESTED I� ly " 9 4 INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my know go-,and that I understand I am responsible for all charges Incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1193