138 Swicegood St w-s.:,,;:,:i-.€.Z4;.w�Y"".as'*ca'si-rs, YY o-.m 1#+i`i"w.,y.rrr'.:a'4 a�`�Q",.+*e7i'sst«-v,^1•r�..; y.=C•.-q;.¢-....__ r... F. =Y .r 4 n, n.•f:,. ' _ .. .r. ..�... .
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S� DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a --
Sanitary Sewage Systems / Permit Number
Name� vf;� �.� ��- !S'� Coo/���� ate ��� %'� N2 7 6 4 Q
Location . Gf/. �'f O t7 l div fart
Subdivision Name Lot No. Sec. or Block No.
Lot Size House � Mobile Home _.T Business Industry
No. Bedrooms .No. Baths _ No. in Family , _ Public Assembly Other
Garbage Disposal YES ❑ NO p ' Specifications for System:
Auto Dish Washer YES NO ❑ n
Auto Wash Ma-hive YES 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.
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 AW414 &I.ea
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Certificate of Completion !_rG Date
"The signing of this certificate shall indicate that the system describedabove 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.
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DAVIE COUNTY, HEALTH DEPARTMENT
�..- IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
,N,OTe.Issued in Compliance With Article 11 of G.S.Chapter 130a
Sanitary Sewage Systems
Permit Number
Name_1 r�_�/�i.� U�Jf,/ 'S'11y �t �'/�°<�>/re-Date __�" �I' :� N2 7640
,Location ��''
m
Subdivision Name Lot No. Sec. or Block No.
Lot Size —_ House Home _ Business _— Industry
No."Bedrooms _,No. Baths _ _ No. in Family _ Public AssembiyOther
Garbage Disposal YES ❑ NO
Specifi ations for System:
Auto Dish Washer YES NO ❑ .
Auto Wash Ma-thine YES �j NO ❑ , �/ " y� . � (�
Type Water Supply
*This permit Void if sewage system described below is not stalled within 5 years from date of issue.
;r- TM's permit is subject to revocation if site plans or the inte•ded use fhange.
Improvements permit b
P Y
*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
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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.
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` &A DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
Vi APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME T�JLCtrr�C'.Q/y C? � PHONE NUMBER
ADDRESS �d ( SUBDIVISION NAME
0/
-X d A 7,0111 LOT#
DIRECTIONS TO SITE 6 61 S fid/-S� ,��`'• fit- v�u�/e��t _���
c>_ l .S
DATE SYSTEM INSTALLED r,01-0,6. NAME SYSTEM INSTALLED UNDER
TYPE FACILITY- NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
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DATE REQUESTED �77 INFORMATION TAKEN BY 1Od11
This is to certify that the information provided is correct to the best of my knowledge,and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
—�
Rev.1/93