P2490 Hwy 158DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`Note. lssue6 in Compliance with G.S. of North Carolina Chapter 130—Article 13c..
Permit Number
Name✓iq r f' 1 i(' /ll�t : %.�</' Date �Y tir, 0
Location �`'~- i �i �. /� - r = �Y
Subdivision Name Lot No. / Sec. or Block No.
Lot Size_ House Mobile Home r✓ Business Speculation
No. Bedrooms No. Baths Z No. in Family 2
Garbage Disposal YES ❑ NO FI]
Auto Dish Washer YES El NO p
Auto Wash Machine YES p --'NO ❑
Type Water Supply
Specifications, for System:
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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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.
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Final Installation Diagram:
System Installed by
Certificate of Completion Date
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*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.
I
DAVIE COMMIT.HEALTH DEPARTDM14T
PERCOLATION TEST RESULTS
DATE
NAAX,
LOCATIOIN
FIIIDI14GS : HOLE 110. CODOE 1TS
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LOT DIAGRAM
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6
9
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NAME
ADDRESS
DAVIE COUNTY HEALTH DEPARTMENT
E11VIRONMENTAL HEALTH SECTION
P. 0. BOX 57
MOCRSVILLEi N.C. 27028-
(704) 634-5985
for Sept c Ta Improvem nes Permits and/or Site Evaluations
�0 e � � - - ., � - ....DATE --'z �� V
r
EXPLANATION OF CHARGE
PERMIT NO.��yg(J
Lo"
A140t3i'i' D SANITARIAN
PLEASE REMIT THE ABOVE P14OUNT ON RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be completed until paynent is received.
Improvements Permits) can not be issued until payment is received...._-