P3749 Byerlys Chapel RdDAVIE COUNTY HEALTH DEPARTMENT
-= IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Se e Tre tment and Disposal Rules (10 NCAC 10A .1934-.1968) i Permit Number
Name Date—��1��`�i'wr�' 3 139
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size f' J'�" House Mobile Home I- ' Business __ Speculation
No. Bedrooms- No. Baths No. in Family _
Garbage Disposal YES ❑ NO 2— Specifications -for System:
Auto Dish Washer YES NO ❑
Auto Wash Machine YES [tj NO ❑ {v{
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 by4YG'99i"�r'�-
�., f
\ ertificate of ompletion ! Date '7
'The signing of this certificate shall indicate t the system described above has been installed in cc plia a with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system wil function
satisfactorily for any given period of time.
APPUCATION FOR SITE EVALUATION/IMPROVEMENTS PERMIt
Davie County Health D,?partment ?�
. Environmental Health Section I 1
4. P 0. Eic+x 665
A4oci(sville, N.C. 27028
CONSTRUCTION SHALL. NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS Biir.N ICfitolRIX
Permit p'¢v `� • Home pgone 483 40 /P
t. d
P6rm R nested E'ay A I Business Phone
2 Address *' 6 a =rP� : N. z1 _. : � A 1 f , a �1a.ra .
9Property Owner If Different than Above
4. Permit To: 4 Install.� Alter Repair__
b) Privy Conventional -e-.' Other Type ---
Ground Absorplion
C) Sub -Division .__ ._ Sec..__ Lot No.
S. System used to serve what type facility: House—_.. Mobile Homey Elusineos_
Industry_.+ Other.___
b) Number of peopled--
8. 8) It ho(.se or mobile home, state size of home and number of rooms.
House Dimensions / >,1,7�
Bed Rooms 3 Bath Rooms.. %- , Dan w/Closet_ _
b) N Business, Industry or Othar, State: Number of persons sc+ried
What type business,--
Estfmate amount'of waste daily (24 hours)—_._
7. Number ane( type of water -using fixtures:
commAes_ —_. urinals_.._—__.—_.__._ _ garbage disposal
lavatory %- _- showers washing machine_ Z
dishwasher _._.L sinks.---
&
inks.—.__8. a) Type water supply. Public____ F'rivate_A_--__"' Community .
b) Has the water supply system been approved? Yes—__ No
9. a) Property Dimensions �D K 9010 g-�°ro-
b) Land area designated to buildi rig sit:+
c) Sewage Disposal
10. Do -you anticipate any additions or expansions of the facility this sewage system is Intended to serve? _
What type?
This Is to cortify that the. information is correct to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR (:OMPUAN::E WITH ALL STATE AND LOCAL LAWS
Allow Ej days for processing
Directions to property:
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