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P3173 Davie Academy RdDAVIE COONTY 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 i:R��: L Sv�a �ht.� Date l — ho —SC 3 N? 3173 Location ,rL2%c�io l tGl- .47-', d4elle< 10.4 ,;e lie. e�ZIJL 4: D:�lu�e Subdivision Name Lot No. Sec. or Block No. Lot Size House J Mobile Home_ Business Speculation No. Bedrooms No. Baths 2-' No. in Family 2' Garbage Disposal YES ❑ NO ❑ Specifications for System: T41A Auto Dish Washer YES ❑ NO ❑ �Z .�, d,F_ 2 00�1� g•X�Z•• �.<<C 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. Qe•D a Improvements permit by • Yea' '�`� *Contact a representativeof a Davie County Health Department -for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. n day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed byU�� Certificate of Completion Date "The signing of this certificate shall indicate that the system'describ d 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 Compliance with G.S. of North Carolina Chapter 130—Article 13c. Permit Number Name Date 0 /J Location Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _ Business Speculation No. Bedrooms No. Baths No. in Family Garbage Disposal Auto Dish Washer Auto Wash Machine Type Water Supply YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ �,..- Specifications for System: *This permit Void if sewage system described below is not installed within 36 months from date of issue. tib III i r * `Y. i � I i { 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 } _., 77 . f , t 1 i 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. 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 l' VC, L Date I - o — l 3� •� Location .%rW 1 AJ- i; blel Subdivision Name Lot No. Sec. or Block No. Lot Size House '� Mobile Home _ Business Speculation No. Bedrooms No. Baths z• No. in Family Z Garbage Disposal YES ❑ NO ❑ Specifications for System:,, •,,- 'i ,>>� - Auto Dish Washer YES ❑ NO ❑ 7 o o' r, Z �,•�. Auto Wash Machine YES❑ NO 0 lii7G(.�� w - Type Water Supply *This permit Void if sewage system described below is not installed within 36 months from date of issue. 1 F% I r ` i d t I Improvements permit by��-'- \. u *Contact a representative of tl,e Davie County Health Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. �n day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed bye --mow" Certificate of Com letion J°��% �< Date " 2-1 P *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 P. O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 2— 7 3 7 2 1. Permit Requested By —Business Phone 2. Address 2+- 7 13 1C S519 Awac�e 2 70 2 P 3. Property Owner if Different than Above Address 4. Permit To: a) Install Alter Repair--L'-- b) epairy b) Privy Conventional Other Type Ground Absorption c) Sub -Division Sec. Lot No. 5. System used to serve what type facility: House `f- Mobile Home Business IndustryOther b) Number of people 2 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 lavatory ers dishwasher inks 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 garbage disposal washing machine 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. 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) .Ti'61'a /4!""— i , e! �//- a-1