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4 DAVIE .COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article II f G.S ChptFr0a
S nitary Sewage Systems . ���a���'�Je " "' V AN�-��� �P� Permit Number
Name `�e /Z i
�9� N2 7758
Location f�_ ..J .
Subdivision Name Lot No. Sec. or Block No.
Lot Size — House 4t�-- Mobile Home Business _— Industry
No. Bedrooms c-2 No. Baths _c2, No. in Family Public Assembly Other
Garbage Disposal YES ❑ NO B' Specifications for System`.
Auto Dish Washer YES NO ❑ ��
Auto Wash Ma shine YES NO El
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
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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.,
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
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Certificate of Completion _fie • 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.
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yjDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION -
*NOTE-Lrssued in Compliance With Article I I Af G.S.?aptyer� 06 °
San�tary Sewage Systems 717,2116"'1 JJ�A". '�F�' Permit Number
Name /I/' ` Z e //sJ' d &/L/--;66L--Date- '/�1!'S'� N2 7 f 5 U
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House
Mobile Home _ Business -- Industry
No. Bedrooms 4.No. Baths _ No. in Family Public Assembly Other
Garbage Disposal YES ❑ NO.®' Specifications for System:
Auto Dish Washer YES NO ❑
Auto Wash Ma^hive YES NO E] p�1Dd.k ila/
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.
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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.,
1:00-1:30 P.M.or 4:30-5:00 P.M.on day of completion.Telephone Number:704-634-5985.
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Final Installation Diagram: System Installed by
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Certificate of Completion Date �l �94
"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
APPLIGATION FOR IMPRO/VEMEN7 PER IT(REPAIR)
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NAME 6AVI`_S PHO p� NUMBER
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ADDRESS Pf SUBDIVISION NAME -
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!S l!,�5 /! - ✓ �S 7/,
LOT#
DIRECTIONS TO SITE f`)'Yl�'Y h-h)-Y�- 4. ` �C.7- ,7, 7 i he Ile. /�cj_ -
DATE SYSTEM INSTALLED 1`1 6119ME SYSTEM INSTALLED UNDER �kY1 Ae r )i e-.
TYPE FACILITY 110 u-S� NUMBER BEDROOMS 2� NUMBER PEOPLE SERVED 4'
TYPE WATER SUPPLY 610W SPECIFY PROBLEM O�URRING ?Gtf'Iwe
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DATE REQUESTED1O'����Y' INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge,and, at I and tand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZ4Q AGENT �+
Rev.1/93 ��\
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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article I Ipf G.S,Cbaptpr�0a
S��i�ary Sewage Systems 7`��'a n �'��J1"D" '9 , �j0�a-�l� �Pr Permit Number
Name .il/',yP //r/– "q/ i ILS Date 1�'/ �y N2 7 7 5 8
�
Location �!. ` ,� 24f7` /�Pl
Subdivision Name / Lot No. Sec. or Block No.
Lot Size _ _ House Mobile Home _ Business .__ Industry
No. Bedrooms No. Baths _c— No. in Family _ Public Assembly Other
Garbage Disposal YES ❑ NO B' Specifications for System:
Auto Dish Washer YES NO E] V
Auto Wash Ma shine YES NO ❑ 070 ��il
Type Water Supply d
'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
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. j
Final Installation Diagram: System Installed by _
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