2219 Hwy 64WA00-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 C oa.
��r,:,> tz�� — ��+�� �, ;SDate
Location W\11 t2 AV -2 _
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile, Home _ Business Speculation
No. Bedrooms_ No. Baths �, No. in Family_
Garbage Disposal YES p NO Specifications for System:
Auto Dish Washer YES [ NO p
/ C) �
Auto Wash Machine YES Eg NO
Type Water Supply C`' ,: k^t-.. _ C) (Z)
L�
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
t
- 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 %. rAl
�-I _- ..
1
Certificate of.Completion ��'='.<y
*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 betaken as a guarantee that the system will function
satisfactorily for any given period of time. ~'
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 %. rAl
�-I _- ..
1
Certificate of.Completion ��'='.<y
*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 betaken as a guarantee that the system will function
satisfactorily for any given period of time. ~'
APPLICATION FOR SITE EVALUATION/IMPROVEM NTS PERMIT �}
Davie County Health Department � - b � qt -g
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
A f Home Phone
1. Permit Requested By kdow C! u,/ Nq c� Business Phone
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install ✓Alter Repair
b) Privy J/ Conventional Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: HouseiefMobile Home Business
IndustryOther
b) Number of people 3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions L3U 2.5q 90-�'
Bed Rooms 3 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 2 urinals
lavatory showers_
dishwasher �p,✓�P
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions / A
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?
q 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
A/
Directions to property:
60 sf,j9,4F Qc( T 64/ 6e, heA,-Wd
s
#ou,2e_ on 4ec�- C'i j l3ox 72- Mocks
DCHD (6-82)