123 Valley Oaks Drive Lot 229.�`°
f 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-.1968) Permit Number
Name ` < Date
Location
3 Va��v d <<s
Subdivision Name 1 I+` ��'� Lot No. 7<' 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: t �-"
Auto Dish Washer YES ❑ NO ❑ �� ( �. ,�'�
Auto Wash Machine YES ❑ NO ❑
Type Water Supply (• ,-,,; i
*This permit Void 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.
Final Installation Diagram: System Installed by W!fes'-
Certificate of Completion — Date 3 "/ YS
e crib above has been installed in compliance with
The signing of this certificate shall indicate that the system d s p
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.
(�a iAor
9:30
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-.1968) Permit Number
Name Ji tW 7_)kAn4 Q,4'n jd Date Z r — Zq ��GI A1%4
/n / :,,')/
Location t %�-�_ V (/�1� ��4 Odle
Subdivision Name VLi j om6l s Lot No. ZZ Sec. or Block No.
Lot Size //0X. ;?-0-3 House `� Mobile Home _ Business Speculation
No. Bedrooms _ No. Baths No. in Family
Garbage Disposal YES ❑ NO ❑ Specifications for System: /00
Auto Dish Washer YES E] NO E]P-Acy– ZDOK 8-,Sc/f- r0�%o
Auto Wash Machine YES ❑ NO ❑
Type Water Supply I "''
'This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit by
u
?.:"30t"A.M.
ct a representative of the Davi County Health Department for final inspection of this system between 8:30-
or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Diagram: / System Installed by�n. S. j,,
Certificate of Completion _ Date a – /
"The signing of this certificate shall indicate that the system describ d 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.
07
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued,iri.,Compliance With G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name ��w�"^�',.h Date - Z �j _.� 3576
(}
Location Lia !f'ia� U till{., 2SL _
Subdivision Name a I Its Qa V i Lot No. —2 Z Sec. or Block No.
Lot Size 110'X Z House Mobile Home _ Business Speculation
No. Bedrooms 3 No Baths No'. in Family —
Garbage Disposal YES ❑ NO [-•-
Auto Dish Washer YES a- NO [] � Specifications z��� r' System: I000
�em:Ste• �a�c
Auto Wash Machine YES F;.;]- NO ,Fj
Type Water"Supply „ lcJNnrnV�
`This permit Void if sewage system described below is -not installed within 36 months from date of issue.
Imp rovements.permit by���
r
"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 WSw.
Certificate of Completion a Date
*The signing of this certificate- shall indicate that the system 'describ d 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-.1968) Permit Number
Name ; i Date
Location—
i
Subdivision Name > > L,, a t Lot No. �- Sec. or Block No.
Lot Size I ! `-'y House Mobile Home _ Business __ Speculation
No. Bedrooms _ No. Baths _ Y No. in Family
Garbage Disposal YES ❑ NO [D Specifications for System:
Auto Dish Washer YES ❑ NO ❑;
Auto Wash Machine YES ❑ NO -❑
Type Water Supply 0!,
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
V
1
1
k
1
Improvements permit by
,t
*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 baJ ")y nrr
Certificate of Completion (I 03P-1 ° 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
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested By �•'^��''ti z� rr►mu "'""' Business Phone
2. Address R -t- I tAJu-
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 Vettle,dkKi Sec. Lot No. 7-2-
5.
z5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people S PK
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms 3 Bath Rooms 2- 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
lavatory —
dishwasher
urinals garbage disposal
showers
sinks
8. a) Type water supply: Public I Private Community.
b) Has the water supply system been approved? Yes,'-- No
9. a) Property Dimensions //o ;t'Zoj
b) Land area designated to building site
washing machine
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 cgrrpct/to the best of my knowledge.
s- i9 -- P
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR CCi1MPLIANO,�"ITH ALL STATE AND LOCAL
Allow 5 days for processing
Directions to property:
DCHD (6-82)
4J# ZZ