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178 E Renee Drive Lot 15DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE' OF COMPLETION ' *Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Arti6le 13c Permit; Number . Name d•i ss,s�' Date! 73. 1'•, Location Subdivision Name _b `� y 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: 6?, ktr� Auto Dish Washer YES ❑ NO ❑ s r <P Auto Wash Machine YES ❑ NO ❑ �� ' 1 Type Water Supply 'This permit Void if sewage system described below is not installed within 36 months from date 'of issue. 1 S f l� i 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 n 1��S /y *,,, 7'.1'x= 'A7� r• Y. ` ps�'�.�•,•.Lt 4 ii',fbb) }:- iI Ce-ti fic ate of�Comion Date #The.si nin of this certificate shall in• >,' 9 9 cfiGate That the sys*66 descri j �;pove has been installed in compliancy with the standards set forth [n ihe,above re iJa#ion, but shall m Uway b Akers as a.guarantee that the system will function satisfactorily for any�giiren'pe6o4d"of time 5 IN ` 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 Name Location Date 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 0 Auto Wash Machine YES ❑ NO ❑ Type Water Supply __— "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 byWmmi-- r� L� (,(tj rtificate of Com tion Date 5–/ - 'The signing of this certificate shall-indi6ate that the syst i,"desc;b- above has been installed in compliance with the standards set forth irrihe:aboVe recAlat�ion, but shall i0vb waytaken: as.a guarantee that the system will function satisfactorily for any given,oeriodof ' r APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 1. Permit F 2. Address CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone` EN`9— 4/07 Z minefcrf RuG�-��N� Business Phone 'j -2- 3. z 3. Property Owner if Different than Above Address 4. Permit To: a) Install Alter Repair b) Privy Conventional Other Type Ground Absorption c) Sub-DivisionSec. Lot No. 5. System used to serve what type facility: House ome 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 3 Bath Rooms Z 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 urinals garbage disposal lavatory showers washing machine dishwasher sinks 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 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. 3-/.�-g� Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: DCHD (6-82) WATER SUPPLY: Source If well, type (Bored) y (Drilled) (Dug) Distance from nearest pollution ft. Form No. 473 (Rev. 9/58) No. of bedrooms Permit Number Date Approved Date Approved by ,�pp Contractor or Plumber Address /��/ 1.�a© Remarks 5 4-A a SEWAGE DISPOSAL RECORD LOCATION OWNER PRIVY: SEPTIC TANK: FHA CASE NUMBER Type Material wood concrete Number Dimensions VA CASE NUMBER New t�� }—? ¢ Volume 67� date Repaired Type secondary treatment , date nitrification line filter trench WATER SUPPLY: Source If well, type (Bored) y (Drilled) (Dug) Distance from nearest pollution ft. Form No. 473 (Rev. 9/58) No. of bedrooms Permit Number Date Approved Date Approved by ,�pp Contractor or Plumber Address /��/ 1.�a© Remarks 5 4-A a SEWAGE DISPOSAL RECORD