358 Martin Luther King Junior Rd DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND; CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G;S of North Carolina Chapter 130 Article 13c
Sewage/reatmeq and Disposal Rules (10 NCAC 10A .1934-.1968) �; Permit Number
Name /s'ii �v {�,;1,?"� �,/�G% Date ".�_ �'
3550
�,-
Location
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 ❑ Specificationsjor�System:
Auto Dish Washer YES ❑ NO ❑ /' '1 �`— �\`�� /'
Auto Wash Machine YES ❑ NO ❑ ��� v s
Type Water Supply
*This permit Void if sewage,system, described below is not installed within 36 months from date of issue.
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• i �l j__
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.
Final Installation Diagram: System Installed by
2�S
6�
Certificate of Completion E� 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.
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS 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 10A .1934-.196 ) Permit Number
Name Date ` ' -%' c:..,
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size%' !' House Mobile Home _ Business Speculation
No. Bedrooms — No. Baths — l No. in Family _.
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑ = f +.�
Auto Wash Machine YES ❑ NO 0
Type Water Supply
---
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
� � t
Improvements permit by —
f
*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. r
Final Installation Diagram: System Installed
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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R O Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Re e t B --'TGk" Business Phone
2. Address C Ala 2 S'!
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Re
b) Privy Conventionalpair Other Type
Ground Absorption
c) Sub-DivisionSec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms Bath Rooms / Den Iw/Closet
T
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 Private Comm ity
b) Has the water supply system been approved? YesNo
9. a) Property Dimensions—
b)
imensions b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify that the information is correct to the best of my knowledge.
Date U Ow#r Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD(6-82)