P7507 Pine Ridge Rd 'Y.rr� ., �'+'•�'"iY'0�ilf� "'f�E Y'"hk-:t-< wy��.. :. .. .. � ,;.:... p
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{. DAVIE COUNTY HEALTH DEPARTMENT lla,�
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETIONy •���
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems _ q Permit Num
Name �� N Date 1 No 7507
ber
Location 0 0 a a 'ter D a
rt
Subdivisi a Lot No. Sec. or Block No,
by °i�"'� House l""' Mobile Home _T Business -- Indust "
Lot .Size�� trye''
No. Bedrooms No. Baths;_--L No. in`Family _ PublicA.ssembly Other ,
Garbage Disposal YES ❑ NO ❑ Specifications for System: <
Auto Dish Washer YES ❑ 4;N0 El o a Cj ok
Auto Wash Ma shine YES VYNO ❑ ` i,
�? _Z � "z
Type Water Supply _ _ —
'This permit Void if sewage system described below isnot installed withfn,5�gears from date of issue.
,,*,This permit is subject to 'r`e'vocation if site plar'5Ior the intended use change.
M �.
a
i
h
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 kl nl_'
a� J-1 '.
Certificate of Completion Date –TA
'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 betaken as a guarantee that the system will function
satisfactorily for any given period of time.
y k 4`-. .w '^) BJP ..`:,..r .,•_...-'l r ..:.-.., - - - • , , - r .. _ . -
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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETIONY i •D
ti*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
.Sanitary Sewage Systems Permit Number
Name ��� SN' Date L—� o 7507
Location t
Subdivisio_iLNamelot No. Sec. or Block No
Lot Size, �y �aF�,ao' House ✓ Mobile Home Business -- Industry
No.--Bedrooms No. Baths No. in Family Public Assembly` `I ' Other
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ '-..,.NO ❑
Auto Wash Ma^hine YES g? NO ❑
Type Water Supply
*This permit Void if sewage system described below is not installed`within 5 years from date of issue.
uThis permit is subject to revocation if site plans'or the intended use change.
QZS
Improvements permit by`—'�..
7 r t
*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.
M 4
Final Installation Diagram: System Installed by �''� \\\
v
t
., 1.. s 1
e � � P' N
p ,
tA
Certificate of Completion - ,Date 1
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, Out shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
�;_ - �..
A DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME Rjb R 0A 'Ccs A t� PHONE NUMBER �� ' �- � 1
ADDRESS Q 3� SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY �e v s c NUMBER BEDROOMS NUMBER PEOPLE SERVED
6�
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED �" b 'r1 INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowled e,and that I understand I am responsible for all charges Incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1193