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518 Pine Ridge Rd x r.��'� y n R,r'+.r e �.«ar' ♦ti,�avi .p ' 7 _ �Ve �.� DAVIE COUNTY, HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE .:OP COMPLETION *NOTE:Issued in Compliance With Article 1I of G.S.Chapter 130a. Sanitary Sewage Systems Permit Number Name��srf , - y Date ?l' 739 Location Subdivision Name Lot No. Sec. or Block No. Lot Size '�`�� House _!/ Mobile Home Business -- Industry No. Bedrooms .No. Baths No. in Family — Public Assembly Other Garbage Disposal YES ❑ NO ❑ Specifications for System: Auto Dish Washer YES ❑ NO Q Auto Wash Ma.hine YES ❑ NO 2--' Type Water 'Supply -:51W XJ_1_/„ *This permit Void if sewage system described below is not installed wit in 5 years from date of issue. This permit is subject to revocation if site plans or the intend e tgnge. fct 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:704634-5985. Final Installation Diagram: System Installed by _ - Cort,Ifcate of Completion Date 'The signing of this certificate shall indicate that the system described above has been installed in compli ce 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,pgrio, ot,time, t APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT a Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Reque tedBy. /' /�-r�� Mailing Address Home Phone L Business Phone 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation 3'Septic Tank Installation Permit 4. System to Serve: 011410use ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # J J C3Basement/Plumbing No. of People SAN/( WAS""" �� ❑ Basement/No Plumbing No. of Bedrooms Er-Oashing 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 Il 7W9 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: �V�e _ AleV e� ©P This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this application - X —Ie DATE Y �� SIGNATURE a� CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MI ICT rJ 1. 1 OWN the property. ❑ 2. I DO NOT OW]dn MUST be completed by the owner or a person authorized by the entativq of the Davie County Health Department to enter upon a o determine said site's suitability for a ground absorption se SIGNATURE