133 Scenic Dr V: '
DAVIE_COUNTY HEALTH DEPARTMENT--
IMPROVEMENTS
EPARTMENTIMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article..13c
Sewage Treatment and Disposal Rules (10 NCAC-1OA .1934-.1968) -*.Permit Number.
Name rY✓ :r- .�',� .- 'i',�ra��'r Datef3741
Location S :j'J`,,,;/�
' Subdivision Name 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 for'System:
Auto Dish Washer YES NO ❑
Auto Wash Machine, YES ] NO ❑ �� r.,� �, ,, ;; s•,
Type Water Supply
'This permit Voidj if sewage system described below is not installed within 36 months from date of issue. .
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.
- I
Final Installation Diagram: System-Installed by
t
Certificate of CompletionDate
`
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."The signing of this certificate shall indicate thatahe system described%bove 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, 'IV r ,'
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 42/.4-- 66'27
1. Permit Reqjjested By. Aa Business Phone
2. Address
1 t
3. Property Owner if Different than Above
Address r
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption f�
c) Sub-Division Sec. Lot No
5. System used to serve what type facility: House--:IC Mobile Home1`Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state si a of home and number of rooms.
House Dimensions
Bed Rooms 1 Bath ooms-1 Rd 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) I j
7. Number and type of water-using fixtures:
commodes rinals garbage disposal
lavatory showers washing machine
dishwasher — sinks 3
8. a) Type water supply: Public Private 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 12L234 iC3 .l.�—� •
10. Do you anticipate any additions or expansions of the facility this sewaa system is intended to serve?
What type? -
This is to certify that the information is correct o the best of my knowledge. _ -
�idA�_.d., 9�
Date Owner Signature_
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
r
1 Allot5 days for p ocessing
Directions t operty:
DCHD(6-82)