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P3350 County Line RdDAVIE -COUNTY HEALTH DEPARTMENT a- IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c Lot Size ,�%� Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Named No. Bedrooms 4N No. Baths Date "�/ „ '' Garbage Disposal :-yV -� _�a3�a Location YES ❑ NO Auto Wash Machine fA��'T T / Subdivision Name Lot No. Sec. or Block No. Lot Size ,�%� House Mobile Home ,>� Business Speculation No. Bedrooms 4N No. Baths No. in Family_ Garbage Disposal YES ❑ NO Specifications for System: Auto Dish Washer YES ❑ NO 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 by ---------------- Certificate of Completion Date *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. APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section 1 R 0. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone g g ? 1. Permit Requested Bye---F//'� Business Phone We 7T 2. Address 3. Property Owner if Different than Above Address 4. Permit To: a) Install A�Alter Repair b) Privy Convention al��Other Type Ground Absorption c) Sub -Division ec lot No. 5. System used to serve what type facility: House obile ome Business IndustryOther b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions /OX/yO Bed Rooms— Bath Rooms 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 lavatory showers dishwasher sinks 8. a) Type water supply: Public PrivateZ,-' Community garbage disposal washing machine 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 th a of y k ow edge Date er Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to p L7A11 7' '1, DCHD (6-82)