830 Yadkin Valley Rd %-�Pr"`^,„.^.,L.'t-s:.•�'4fi iPZ�.�-Yb E'7•':.`'..t.;c3 r. y .. '1 _.3.r�%;r+i � .-:'t. ,�_,.,W'. , . ..,...: `.-.
r - DAVIE COUNTY HEALTH DEPARTMENT
` IMPROVEMENTS PERMIT AND, CERTIFICATE OF COMPLETION
NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a / / �A;��� - - -
/S�n,itpry,SLewage S tems �/ ;i �C' Permit Number
Name-1�-- 4 c� - ��'�✓Date ��.?.�/g� NO 7698
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House _ Mobile Home — Business _ — Industry
_No. Bedrooms .No. Baths --4— No. in Family Public Assembly Other
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑
Auto Wash Ma^hine 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 —
U"D"
Certificate of Completion Date Y
'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.
DAVIE COJilNTY HEALTH DEPARTMENT
w " IMPROVEMENTS PERMIT AND` CERTIFICATE"O_ F COMPLETION `--`
. .f -
/ '*NOTE: San tdin ry Sewage SceWith tems Article II of G.S.Chapter 1430a �,J permit Number.
g //
Name_ z" , ti �1�Date i���/ ND
- 7698
Location _
Subdivision Name Lot No. Sec. or Block No.
Lot Size ' _ House , Mobile Home — Business —_ Industry-Bedrooms _ —.No. Baths _ _ No. in Family �= Public Assem Other
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO;E] p y
Auto Wash Ma^hine YES [],,..NO
❑ ��S"r �-S / J�
f 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.
Ll
y
Improvewnts permit by — 1
*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 —
i
Certificate of Completion_ Date 7
'The signing of this certificate shall,indicate',that the system described above has been installed in compliance with
the standards set forth in the aboveregulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of_V1me.
'
$0) "2-04XVIE10
COUNTY ENVIRONMENTAL HEALTH SECTION
PPLICATION FOR IMPROVEMENT PERMIT(REPAIR) p-- p
NAME 1.- Y PHONE NUMBER
ADDRESS nl r c /-LSE'-J C - SUBDIVISION NAME
yy e �ir LOT #
DIRECTIONS TO SITE l f I -f-440 7 V'.gJlel x- V(S7
Ic-i xb
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER fff• Avmer-
TYPE
FACILITY IvNUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
n r
S are rru rr.b )i }at? i' 91� r-die
DATE REQUESTED �� ��T INFORMATION TAKEN BY
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.1/83