160 Powell Road Lot 9CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Construction Authorization
CDP File Number: 199815 -1
County File Number:
Date:02/25/016
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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Ik VFX f�%�u'�G�L/S Date
Name _
Location —
//_D oty.„ iley r
Subdivision Name Of t .+�(/t�L,� Lot No. --- Sec. or Block No.
Lot Size y House Mobile Home — Business — Speculation `
No. Bedrooms —-- No. Baths — No. in Family — - p
Garbage Disposal YES ❑ NO ❑- Specifications for System: �QQGrI� iCIL(�
Auto Dish Washer YES 2- NO ❑ x D
Auto Wash Machine YES [I NO ❑
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Type Water Supply Scri,�ch Z�/WCS✓ i� 7 , ,f r,
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*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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Improvements permit by
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30 -
►846 r 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation
System Installed by
ri
Certificate of Completion Date A O A
*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',CO.UNTY HEALTH ~DEPARTMENT
IMPROVEMENTS •PERMIT AND. ,CERTIFICATE OF COMPLETION
*Note: -Issued in Compliance with G S �of North Carolina Chapter 130L -Article 13c.
V Permit Number
Name gU t �u . �� A S Date ���
TT
Location W
Subdivision Name ��l0300ro, ACAP 1-,r' Lot No. Sec. or Block No.
Lot Size 100 _')n a House '� Mobile Home _ Business Speculation'
No. Bedrooms _ No. Baths No. in Family _-
Garbage Disposal YES'C NO fl
Auto Dish Washer YES 0' 'NO ,fl Specifications for System: Spa ca/. %,fa e.
Auto Wash Machine YES fj* ',NO
s 7s -,X_3 xv �? V,'ROC K
' Type Water Supply'
*.This permit Void if sewage system described below is not installed within 36 months from date of issue.
1 ,
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Certificate of.Completion ate
"The signing of this certificate shall indicate that the system 11 described above ha.1 been` installed�m,Qompliance with
the standards set forth in the above regulation, but'shall- in NO way betaken as a guarantee that the sys 6m Will function
satisfactorily for. any given period of time: �` �.
DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
MOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAPE �r '
ADDRESS
DATE ISSUED !aIYIW
PERMIT NO. ,?a 13
Explanation of charge 4W
AMOUNT DUE a%d'o
PLEASE REMIT THE ABOVE AMOUNT
SANITARIAN.
ON RECEIPT OF THIS STATEMENT.
4 60,x
DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST
APPLICATION IP/ATC OSWW REPAIR
Name r an I Ne, IAO �' N TP1PnhnnP NnmhPr ���`��,2✓/
Address /(/o kwe i
Mailing Address (if different from above)
Email Address:
Subdivision Name. h5 w
��,,
Directions 1/l a l
Date System Installed /7111
Type Facility (-SP,
Type Water Supply �/S!I A (4 -
SO
Lot #
Name System Installed Under
Number Bedrooms-_ Number People Served
Specific Problem Occurring %ryn
Date Requested - 5�— Info Taken By
THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY
KNOWLEDGE, AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED
FROM THIS APPLICATION.
Signature of owner or Authorized Agent
Initial Fee Date
Revisit Charge Date
REHS
Reason