P2203 WoodlandDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF Cowl= ETION-
*Note: Ii s -de- 'in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name ✓6�%d..S.'.�� Date 2?03
Location ,r,l?/
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 ;E] NO p'`"" Specifications for System
Auto Dish Washer YES NO 0 _Are
Auto Wash Machine" YES R N_O-,[� ��137
�d
41L
• Type Water Supply � • - .
*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 _
A,
s
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'.
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'Note: Iasued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name r! Date
Location
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 ❑ NO ❑ Specifications for System:
Auto Dish Washer YES [j NO ❑'_
Auto Wash Machine YES O; `NO -❑ r
Type Water Supply _ J __—
"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
I
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.
DAVIB COUIM. HEALTH DEPARTMENT
PERCOLATION TEST RESULTS
DATE L� 1
LOCATIOid
FINDINGS: HOLE 140.
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• DAVIE COUNTY HEALTH DEPART.lENT
SITE EVALUATION CONSENT FORM
INSTRUCTIONS/PREREQUISTES
1. Complete the form below and return it to the Davie Co. Health Department.
2. Along with the form, remit the amount due as shown on enclosed statement.
3. Carefully follow the procedures as outlined in the enclosed "Information
Bulletin".
4. Notify Health Department upon completion of item number 3.
NOTE: ALL THE ABOVE 14UST BE DONE BEFORE A SANITARIAN WILL BE ABLE
TO BEGIN THE REQUESTED EVALUATION.
DETACH HERE AND RETURN TO THE(DAVIE COUNTY HEALTH DEPARTr1ENT,P.O. BOX 57)
(MOCKSVILLE, N.C. 27028)
DAVIE COUNTY HEALTH DEPARTMENT
SITE EVALUATION CONSENT FORM
LOCATION OF PROPERTY:
DATE RECEIVED
(offic3e use dnly)
yes no (1.) I am the owner of the above described property.
yes no (2.) I am not the owner of the above described propjrty, however, I
certify that I have consent from Jo S. Mehr -et - owner to
0 1�1— owner's name
obtain a site evaluation by the Health Department for the purpose
of determining the suitability for a ground absorption sewage
disposal system.
yes no (3.) I hereby give consent to the authorized representative of the
I Davie County Health Department to enter upon the above described
property and conduct all testing procedures necessary to
determine its suitability for a ground absorption sewage
disposal system. 4— I
/.2-� / 5 r � �)�
DATE IGNATURE
(4.) I hereby authorize the Davie County Health Department to release
site evaluation results from the above described property to the
following:
L1. Owner Only
fj Owner's designated representative
0 Anyone requesting results
DATE C --Only those listed below
I NATURE
DAVIE COUNTY HEALTH DEPARTME
P. 0. BOX 57
MOCKSVILLE, N. C. 27028
(7 04) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations'
NAME DATE ISSUED (/
�l� ''f
ADDRESS PERMIT NO.
Explanation of charge
' 1 r
AMOUNT DUFy/V � SANITARIAN rx!
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.
.
r
DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
MOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Imp ovement Permits
and/o Site Eval io
NA' !IB �-S f /' DATE ISSUED
ADDRESS PERMIT NO.
Explanation of charge
AMOUNT DUE ��/� / SANITARIAN
PLEASE REMIT THE ABOVE AIIOUNT ON RECEIPT OF THIS STATEMENT.