249 Oak Grove Church Rd DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems 4/11 Ile Permit Number
Name ate � Q� NO 7981
Location -�- �� o.�` E_�/�121
_ /f�wn f•-1�� 7�
Subdivision Name Lot No. Sec. or Block No.
Lot Size __ _ House '�"�Mobile Home -___ Business _— Industry
No. Bedrooms - ..No. Baths _s�.-- No. in Family Public Assembly Other
Garbage Disposal YES p NO [2' Specifications for System: 7—
Auto
Auto Dish Washer YES NO
Auto Wash Ma^hine . 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
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM. ?
gip'
. ran' WPI
� STS
17
r
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
Certificate of Completion Dater�� L1
'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.
O
-" DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
---tike E:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems fii: , i PermitNumber
Name ~�"U)Z_'rT Ali%�f�,r��r��% r. - r�<�•P%Date _� � ✓- f S� N2 7981
Location —
Subdivision Name Lot No. Sec. or Block No.
Lot Size -- — House _ "'�~ Mobile Home ____ Business —_ Industry
No. Bedrooms -- _.No. Baths _ — No. in Family -Z Public Assembly Other
Garbage Disposal YES ❑ NO C?' Specifications for System: C if l/= 7—
Auto
Auto Dish Washer YES NO ❑
Auto Wash Ma^hine 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
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM.
y-it I1
r-
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
67
Btvi/l
�r
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.
w
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
cy APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME G'T osaP�/ D� PHONE NUMBER
ADDRESS 4552 SUBDIVISION NAME
LOT#
DIRECTIONS TO SITE ���� �T- �� 8�-✓ /� �r
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY C10 SPECIFY PROBLEM OCCURRING
DATE REQUESTED '�/�/� S INFORMATION TAKEN BY
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.1193