P6240 Boger RdDAVIE COUNTY HEALTH DEPARTMENT -1I
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETIOW
*NOTE: Issued in Compliance With Article I I of G.S. Chapter 130a
Sanitary Sewage Systems Permit Number
Name %11 �/J �'` t. , "� /,: /yN2 6240
Location ✓. �?_� "i- ,*:�%ir,;
Subdivision Name Lot No. Sec. or Block No.
Lot SizeHouse Mobile Home Business Speculation
No. Bedrooms No. Baths / k!2 No. in Family --T _
Garbage Disposal YES ❑ NO [2- Specifications for System:
Auto Dish Washer YES NO ❑
Auto Wash Machine- YES T NO ❑ `�����`�� �` ,
Type Water Supply _
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change. 6,
s
Alli
r
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
Certificate of Completion a / Date �/l
*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. (�
I.
' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
' Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By.
Mailing Address �l'/n� �7S�7
Home Phone ,W-7,2 Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For: 0 General Evaluation G--37Tank Installation
5. System to Serve: House bile Home Business
Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People —5-1 Dwelling Dimensions
No. of Bedrooms —1? Basement/Plumbing
No. of Bathrooms] V -Q Basement/No Plumbing
0 Washing Machine 0 Dishwasher 0 Garbage Disposai
7. If business, industry, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories _
No. of Showers
No. of Sinks
No. of Urinals
No. of Water Coolers
8. Type of water supply:ublic 0 Private 0 Community
9. Property Dimensions Je2
10. Sewage Disposal Contractor
11. Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes a-lq'o
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of 5
years from date issued. Improvements Permits are subject
to revocation, if site plane or the intended use change.
Effective October 1, 1989.
This is to certify that the information provided is correct to the
best of my knowledge, and I understand I am responsible for all
charges incurred from this applica ion
�2AS 2 16;e)'
Date Signature
Directions to Property:
DCHD (10-89)