1169 Baltimore RdYXb
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
* NOTE: Issued in Compliance With Article I I of G.S. Chapter 130a
Sanitary Sewage Sy t
ms Al Permit Number
Name S �e "o Sy
�? � No I 7 I' Ll
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size �C House —!lam_ Mobile Home _ Business -- Industry
No. Bedrooms �2 No. Baths No. in Family �� _ Public Assembly Other
Garbage Disposal YES p NO 2110' Specifications for System:
Autoish Washer YES r NO p A
Auto Wash Ma^hine YES NO X-�/t
Type Water Supply azzZ
*This perm i ea>_deapribed below is not installed within 5 years from date of issue.
This permit is subject to revocation if site pld-nlmr4 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
Certificate of Completion Date ` I
�1
*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 Com I'ance With Article I I of G S C:ha t r 130a
Sanitary Sewage Systems ; / Permit Number
Name �L�i S� �/ e 'In' N2 17Vc
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business ,_ Industry
No. Bedrooms 6-2 .No. Baths No. in Family �� Public Assembly Other
Garbage Disposal YES ❑ NO;pj-' Specifications for System:
Auto fish Washer YES NO ❑
4.
Auto/wash Ma^hine YES T NO ❑ �w A ,0"
Type Water Supply _ 4�2 f1
'This perm itafoid-if-sewage-systemAescribed below is not installed within 5 years from date of issue.
This permit is subject to revocation if site p anland `or -t intended use change.
---------------
Improvements permit bY_Ll L—
'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
4
Certificate -of Completion Date I
*The signing of this certifidat'2'shal1,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.
i
i
Certificate -of Completion Date I
*The signing of this certifidat'2'shal1,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.
i
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
�yJ APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME o®�%�e �i /coni PHONE NUMBER
ADDRESS ,a/!��r� �C/ SUBDIVISION NAME
AllC (d O� LOT #
DIRECTIONS TO S
DATE SYSTEM INSTALLED cTO Yl ✓- NAME SYSTEM INSTALLED UNDER
VV
TYPE FACILITY DWe- NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED �� /�0/9y INFORMATION TAKEN BY.
This is to certify that the information provided is correct to the best of my knowled",and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93