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303 Midway Dr _ u DAVIE COUNTY HEALTH DEPARTMENT �~ - IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c. Permit Number Name Date Location Subdivision Name Lot No. Sec. or Block No. Lot Size yC� A` House `ter Mobile Home _ Business Speculation No. Bedrooms No. Baths No. in Family Garbage Disposal YES q NO Specifications for System: Auto Dish Washer YES NO ❑ SCI JET` S A 1 ; Auto.W?sh Machine YES p NO ❑ Type Water Supply C- _— *This permit Void if sewage system described below is not installed within 36 months from date of issue. OIL C> J7 L j oL k CID Improvements permit by =2)- S 1 *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 IV 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. .s APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section .P. 0. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone- 6 ^ 7G 1. Permit Requested By 3c'-c kY PP/LE c Business Phone 2. Address T. t�ctX 20© A S -rr_c✓ «r we 3. Property Owner if Different than Above Address 4. Permit To: a) Install Alter Repair b) Privy Conventional tfther Type Ground Absorption c) Sub-Division Sec. Lot No. 5. System used to serve what type facility: House ­1l�lobile Home Business — b) IndustryOther b) Number of people—c� 6. a) If house or mobile home, state size of home and number of rooms. House Dime ons Bed Rooms Bath Rooms Z Den w/Closet b) If Business, Industry or Other, State: Number of persons served What type business, etc. Estimate amount of Waste daily (24 hours) 7. Number and type of water-using fixtures: commodes urinals garbage disposal lavatory showers washing machine dishwasher sinks 8. a) Type water supply: Public Private �Community b) Has the water supply systpm beep approved? Yes No 9. a) Property Dimensions :Z A-r b) Land area designated to building site c) Sewage Disposal Contractor 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? What type? This is to certify that the information is r ct to the a of y knowledge. �- 3 - 2i/Z_ Date Owner Signat OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE D LOCAL LAWS Allow 5 days for processing Directions to property: 0 DCHD(6-82)