P4072 Madison Rdr� -
�` DAVIE COUNTY HEALTH DEPARTMENT
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IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
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 i`/ �, � ,�;,n Date / /% / � HT 4072
Location /Z
Subdivision Name
Lot No.
Lot Size
House =— Mobile Home.
No. Bedrooms .�
No. Baths No. in Family _
Garbage Disposal
YES ❑ NO ❑----
Auto Dish Washer
YES ❑ NO ❑
Auto Wash Machine
YES NO ❑
t
Type Water Supply
_—
Sec. or Block No.
Business
Specifications for System:
Speculation
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
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
Certificate of Completion Date
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.