132 Pine Ridge Rd t
y S ,SQDAVIE COUNTY HEALTH DEPARTMENT
peelAMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a ,E
Sanitary Sew a a Systems - Permit Number
Name �° -�/• �. i' / Date &L l o� 5953
Location ,..
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms _AI&A 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 r
*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.
f
a
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
- ,No (!X
u
z p
El
Certificate of Completion Date " 9
*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.
1
41�M
DAVIE COUNTY HEALTH DEPARTMENT
PROVEMENTS PERMITAND CERTIFICATE OF COMPLETION
^:
r
NOTE:Issued in Compliance With Articled l of G.S.Chapter 130a
,`,Sanitary Sewa a Systems J - Permit Number
Date '�� = �/• � ' NO 595
L.dcation
Subdivision Name v Lot No. Sec. or Block No.
Lot Size House Mobile Home — Business Speculation
No. Bedrooms No. Baths —_ No. in Family
Garbage Disposal YES ❑ NO Specifications foi >System:
Auto Dish Washer -YES E] ., NO
Auto Wash Machine YES E] NO c /cDG�rG`-
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.
t
vl
j
t
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
(Jo of f
Em
r ,
NUS
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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
a Davie County Health Department jge dee
Environmental Health Section C/•�1 �(J
P. 0. Box 665
Mockoville, NC 27028
1 . Application/Permit Requested By 1l&A;Mi5 H • P&4-5L
Mailing Address Ri. 4 Q ak go (. Moc'ksvi /1e, N.C. a 7aaff
Home Phone O N- 0l0 7c5 Business Phone . -74/' 3TC S
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For : 0 General Evaluation (►"S/Tank Installation
5. System to Serve: House Mobile Home Business
L Industry u Other Unknown
6. If house, mobile home: Subdivision Sec. Lotti
No. of People _ Dwelling Dimensions /7qb S4.
No. of Bedrooms Basement/Plumbing
No. of Bathrooms I Basement/No Plumbing
0 Washing Machine J Dishwasher 0 Garbage Dispusai
7. If business, industry, 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
8. Type of water supply: Public @,f'rivate 0 Community
9. Property Dimensions
10. Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes g"'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.
This is to certify that the information provided is correct to tree
best of my knowledge, and I understand I am responsible for. all
charges incurred from this application.
Date Signa re
Directions to Property :
IIFVV
DCHD (10-89)