493 Mr Henry Rd (2) `'' DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 1(`!
*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 /, r � r Date JI�,/ .7 7G
Location
l r l
Subdivision Name Lot No. Sec. or Block No.
Lot Size ` House Mobile Home =.Y Business Speculation
No. Bedrooms y No. Baths No. in Family
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑ - �=
Auto Wash Machine YES ❑ NO •❑
Type Water Supply _—
"This permit Void if sewage system described below is not installed within 36 months roti date of issue.
L
LI
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 a !� }�,� Y 1�a Y�
,
I
1 �
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 shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
APPUCATION FOR SITE EVALLI TION/IMPROVEMENTS PERMIT
t f Davie County Health D,spa►tment
' Environmental Heallh Section
V'
P. 0. fk,x 665
Mocksville. N.C. 27028
CONSTRUCTION SFIALL NOT BEGIN UNTIL lKIPROVEMENTS PERMIT HAS NEN ISWEID,
�f Home rgone
1. Permit Requ sled By --.�/ �_�F_1W;II qrn Business Phone 99�A iia
2 Address
a Property Owner ff Different than Above lif
_ Address R.e u yA,7-r
4. Permit To: a) Install-tf.-Alt ei Reps i r
b) Privy Comrentional_4!(5ther Type,__
Ground At*orplion
c) Sub-Division,_ Sec. _ Lot No.
d. System used to servo what type facility: House___..Mobile Home Business—
Indust-y--Other__-
b) Number of people_
8. a) It house or mobile home,state size of home and number of rooms.
House DimensionsA�l.XZd
Bed Rooms 3 Bath Rooms-.2 _Dan w/Closet. ..
b) M Business, Industry or Othar, State: Number of persons served —
What type business,
Estimate amounfol waste dally (2-4 hours)---
7.
ours).___ _.—_.-_7. Number anqtypo of water-using fixtures:
commodes a __. urinals_.._—___—__ ._— garbage disposal
lavatory showers__ a- —.._ .washing machine_ l
dishwaaber sinks _...—_...
8. a)Type water supply Public____F'rivate_-A' Community
b) Has the water supply system been approved? Yes ✓ No_.-._
9. a) Property Dimensions� _ D_—__
b) Land area designated to building sit:
c) Sewage Disposal Contractor •--
10. Do you anticipate any additions or expansions of the facility tris, sewage cystem.is Intended to serve?
What type?
This Is to cortify that the.information is correct to the best of my knowledge.
Date Owner Signa
OWNER IS SOLELY RESPON'31BLE FOR COM?LIA:V;;E WITH ALL STATE AND LOCAL LAWS
Allow 6 days for processing
Directions to properly:.
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