383 Pleasant Acre Dr J DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
/Sanitary Se g�Sy 'gems ����/,�, Permit Number
Name �,i �1 r�� Ilii ���t �i 'r �Date � No 5 80 2
Locatio ;i
Subdivision Name Lot No. Sec. or Block No.
Lot Size House _ 4e::�—' - Mobile Home — Business _— Speculation
No. Bedrooms _ No. Baths Z No. in Family
Garbage Disposal YES ❑ NO 0' Specifications for System:
Auto Dish Washer YES } NO ❑ /DO C�
Auto Wash Machine YES [(j NO ❑
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.
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. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Ifn
Final Installation Diagram: System Installed by
0
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.
1
DAVIE COUNTY HEALTH DEPARTMENT
'.IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*66.. Issued in Compliance With Article I I of G.S.Chapter 130a
... Sanitary SevagpSystems Pe
rmit Number
N me te N2
5802
Locatio, f /i�,
Subdivision Name Lot No. Sec. or Block No.
Lot Size House 4ef—' Mobile Home _ Business Speculation
No. Bedrooms _ No. Baths - Z No. in Family _
Garbage Disposal YES ❑ NO p' Specifications for System:
Auto Dish Washer YES NO ❑
Auto Wash Machine YES NO ❑ '��� .x-�y
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.
Improvements permit by — A
*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
V '
1•
l�
Certificate of Completion Gam/' 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, but shall in NO way be taken as a guarantee that the system will function
satisfactorily any Y 9wen period of time.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
{� Environmental Health Section
1� R O. Box 665
Mocksville, N.C. 27028
0/
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
_ Home Phone
1. Permit Requested By �' �� �/� ��°� SSP Business Phone
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people
6. ay If house or mobile home, state size of home and number of rooms.
House Dimensions e
Bed Rooms Bath Rooms—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 Privateer Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions
b) Land area designated to building site /
c) Sewage Disposal Contractor ' �' . -r�
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
f
This is to certify that the information is co ect to the be my knowledge.
Date Oibner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
is
*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.
j Effective October 1, 1989. -
DCHD(6-82)