1204 Milling Rd � ��`'L-'4'S.�Iv YP'9Y""�`iF'R�:+.�,�„tP�ti'}`#r vr:.c!�ft..�'a -`•.'. t',t ` .. "'7'Sxr,.-`rr-"' �..•.�.:t'> ' 4. - .(. -.a� rr a.d�,r.� +.-.i; 1".;F'i a,�I�:.,r.:u� -.y -y...a r;�:'�y'.
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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With ArticleiI of G.S.Chapter 130a
Sa itary Sewage Systems Permit Number
me
Date �� ,��� N2 7 3 7 7
0 �K
Subdivision-Name Lot No. Sec. or Block No.
Lot Size House 4e!!!� Mobile Home _ Business Industry
No. Bedrooms No. Baths _ No. in Family-�,.3_ Public Assembly Other-
Garbage Disposal YES ❑ NO �— �•-3 Specifications for System:
Auto Dish Washer YES ❑ NO
Auto Wash Ma-.hive YES ❑ NO
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. '' +
L
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:704-634-5985.
Final Installation Diagram: System Installed by
b
S'
a
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 hall',in NO way be taken as a guarantee that the system will function
j satisfactorily for any given period of time.
;, -
0J.
DAVIE COUNTY-'HEALTH DEPARTMENT
y .; IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION=
*NOTE:Issued in Compliance With Articled of G.S.Chapter 13108
Sanitary Sewage Systems Permit Number
_ _ e ,,IJ ///� 9E� � Date J'�'��'�'-�� N2 13 7 7
Subdivision'Name Lot No. Sec. or Block No.
Lot Size House —1L Mobile Home _T Business -- Industry %
No. Bedrooms No. Baths r No. in Family -5_ Public Assembly `10ther—
Garbage Disposal YES ❑ NO (�- Specifications for System:
Auto Dish Washer YES ❑ NO [
Auto Wash Ma shine YES ❑ NO [.y
Type Water Supply _ ----
'This permit Void if sewage system described below isnot installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
. i
Improvements permit by —112//
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M., t
1:00-1:30 P.M.or 4:30-5:00 P.M.on daj of completion.Telephone Number:704-634-5985.
F
Final Installation Diagram: System Installed by
3
Certificate of Completion \- Date a 9
'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 ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) / p�
NAME �17. e5 �I7�Z PHONE NUMBER
Q �
ADDRESS eO � .t) O� SUBDIVISION NAME
LOT#
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY ;arC NUMBER BEDROOMS S NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED /,���-"�� INFORMATION TAKEN BY /I
This is to certify that the information provided is correct to the best of my knowledge,and that I understand I am responsible for all charges Incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93