312 or 328 Harper Rds s
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
- Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number.
Name' r" -ter' ,.,� r, Date 3867
�.
Location 0 1 0 `-i
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home Business Speculation
No. Bedrooms 7 No. Baths No. in Family
Garbage Disposal YES ❑ NO ❑ Specifications for System:lOou �«Q
Auto Dish Washer YES p NO ❑ -� i3u j `� ,���. �,�� ` .. ,��crc
Auto Wash Machine YES p 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 r, r
*Contact a representative of the Davie County Health Department forfi�nnal inspect' of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone N m�ier: 704.634-59
Final Installation Diagram:
System Irfstalled
n
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
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
F4.ek
1. Permit Requested By
2. Address
Q
3. Property Owner if Different than Above S -�
Address
4. Permit To: a) Install Iter Repair
b) Privy Conventional Other Type
Ground Absorption
Home Phone—
Business Phone
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home-±::::fBusiness
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms 2' 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
lavatory
dishwasher
urinal
showers
sinks
garbage disposal
washing machine
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
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:
�I
DCHD (6-82)
STATEMENT
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
210 HOSPITAL STREET
P. 0. BOX 665
MOCKSVILLE, NORTH CAROLINA 27028
(704) 634-5985
DATE y -"b '
t,L(2
0. c f\
L I
DETACH AND MAIL WITH YOUR CHECK. YOUR CANCELLED CHECK IS YOUR RECEIPT.