156 Duard Reavis Rd (3)bcy"Y�'r`Yv; .,.�.�,.cru..--a�;.s:.:n�,A,-wat+W'.:,`�d.,+.p �`r""..r:MoStr+'.Vr."lA"P' `..aA'W'�""'silo-`s'FYiwti�9'v�.•..�x�^a Y..,Y '°''"'e'en w,.r �R'A�`W'-V+'.'w. �
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lie DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a
tSanitary Sewage Syst ms Permit Number
Name `�'1 N N szc� e rv.� s�C �c�� Date ' 3 - 93 No 71.47
Location
� = \6
Subdivision Name Lot No. Sec. or Block No.
Lot Size y House Mobile. Home _T Business__ Speculation
-r
No. Bedrooms No. Baths f No. in Family—
Garbage Disposal ,; YES [D..,. -NO
Specifications for System: - 1^'j ok
Auto Dish Washer YES ❑ NO ln :s
n
Auto Wash Ma thine F YES ' NO C] 'y a
Type Water Supply
'This permit Void if sewage system described below isnot installed within 5 years from date of issue.$
This permit is subject to revocation if site plans or the intended use change..
LU
'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 _1 Kt44�s w�-
,.l,
4
Co G -p
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.
r
—s—
�7
NAME_
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
-N r'4- CL
HONE NUMBER 4q2 - YS11-
ADDRESS 0.6 6� 131 Vara. SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE ( O l N (1, &-a, Cr - CI•- Rr/- 2-� b>`�� l,Aw
P44 6P -, CA, a VACb-
DATE SYSTEM INSTALLED 101631 NAME SYSTEM INSTALLED UNDER
TYPE FACILITY Nwl>c_ NUMBER BEDROOMS NUMBER PEOPLE SERVED G
TYPE WATER SUPPLY ,QrN cl t w9A ( SPECIFY PROBLEM OCCURRING S"p_
-6v- tLV-i
DATE REQUESTED S" 3 3 INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT,
Rev. 1193