P4164 Liberty Church RdDAVIE 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
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Name � ���2 1 � �✓(�� �� Date
Location l' �� /i �� ,'% _ / .�: i�J" �'� i /•;' f' - S
Subdivision Name Lot No. Sec. or Block No.
Lot SizeXHouse Mobile Home __ Business Speculation
No. Bedrooms No. Baths No. in Family
v -
Garbage Disposal YES ❑ NO p' Specifications for System:
Auto Dish Washer YES NO ❑ �'
Auto Wash Machine YES p NO F❑ /l"t
Type Water Supply�- ���Arl41-�'�
`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.
Final Installation Diagram:
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
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED/ p
T Home Phone A�,_ 23L�J
1. Permit Requested By –FIM SfF_L Business Phone
2. Address 'Ri '7 On V 377-2 %nom U I) 10, /� 0. a %62 9)
3. Property Owner if Different than Above
Address
4. Permit To: a) Installer Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division Sec. Lot o,
ines
5. System used to serve what type facility: House Mobile Home Buss
IndustryOther
b) Number of people h
� +R��
6. a) If house od obile hom , state size of home and number of rooms. Zmj,, "
House Dimensions
Bed Rooms 3 Bath Rooms -9- 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 garbage disposal
lavatory showers -2 washing machine /
dishwasher i sinks /
8. a) Type water supply: Public Private— Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 180 Faz,r bw. )7D FEET
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.
Bye
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD (6-82)