114 Pepperstone Dr Lot 2 7.
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 Permit Number
Name ;% 1-�� /CAS/•t��'// `l. CJk �1Iv-1�� Date nom' � J _ N2 8168
Location
Subdivision Name ; F',` ��' %✓'f of No. Sec. or Block No.
Lot SizeHouse _tr''_ Mobile Home Business _— Industry
No. Bedrooms `f—.No. Baths --/'2--- No. in Family 4,) — Public Assembly Other
Garbage Disposal YES ❑ NO Q-- Specifications for System:
Auto Dish Washer YES E3-'NO ❑ ,J
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Auto Wash Ma^hine YES C?--'NO ❑ /1sG' �a� " f
Type Water Supply -- ----- --- �.5'G�I�X.�X/�
'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.
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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 - � S• ��
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Certificate of Completion —G ----_ Date /X J()<r'S _
'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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE M
Davie County Health Department a `'
Environmental Health Section
P. O. Box 665 ,, , 2
Mocksville, NC 27028
L Woor
1. Application/Permit Requested By
Mailing Address x(,.19--t4 Home Phone
42 �,.h NC Z 7d,?2 Business Phone G�35� lf'/y7
2. Name on Permit if Different than Above
3. Application for: ❑General Evaluation Septic Tank Installation Permit
4. System to Serve: $1 House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other _ ❑ Unknown
5. If house, mobile home: Subdivision Section Lot # 1<19
® ❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms J7 Washing Machine
No. of Bathrooms Dishwasher
Dwelling Dimensions ❑ Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: Public ❑ Private ❑ Community
8. Property Dimensions Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property:
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This is to certify that the information provided is correct to the best of my knowledge, and I unders and I am responsible for all charges
incurred from this application.
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: I OWN the property. ❑ 2. I DO NOT OW]ee
If you checked Box#2, the rest of this form MUST be completed by the owner or a person authorized by the I hereby give consent to the authorized representative of the Davie County Health Department to enter upon aproperty located in Davie County and owned byto conduct all testing procedures as necessary to determine aid site's suitability for a gro nd absorption se
and disposal system.
DATE SIGNATURE
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