147 Creekwood Drive Lot 61 (2) DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130-Article 13C)
OWNER OR CONTRACTOR D - DATE M 'w % PERMIT
LOCATIONA/7 N? 1182
S.R. NO.
SUBDIVISION NAME LOT NO. (o l SECTION OR BLOCK NO. �+
HOUSE MOBILE HOME E3 BUSINESS ❑
House Trailer 800 Gal. 400 Sq. Ft.
N0. BEDROOMS N0. BATHROOMS Two Bedroom House 800 Gal. 600 Sq. Ft.
GARBAGE DISPOSAL UNIT YES ❑ NO ❑ Three Bedroom House 900 Gal. 900 Sq. Ft.
AUTO. DISHWASHER YES ❑ NO ❑ Four Bedroom House 1000 Gal. 1200 Sq. Ft.
AUTO. WASH. MACHINE YES ❑- NO ❑
SITE SUITABLE YES ❑ NO ❑
SIZE OF TANK gal. ,
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual Public ❑
IMPROVEMENTS PERMIT BYr`�G4 w. 3 INSTALLED BY
v
CERTIFICATE OF COMPLETION
BYQ�'-C''SMa"�`' Date 10-
(8/16/73) *Construction must comply with all other applicable State and local regulations
LOT AREA . �: 'E 4.. ► , r<:. Y,.
a a. .. j4avie County Health Department _
t`
ILI' N.4 �; mvlronmental Health Section
4 e�
7011 P.O.-Box 848 :
21.0 Hospital Street
f
1. Fr Courier# :09-40-06 1
Mocksville, NC 27028 �a
Phone:(336)-753-6780 Fax:(336) -753-1680
ON-SITE WASTEWATER CERTIFICATIONVOR DWELLING
(Check One) Replacement Remodeling-/ Reconnection
Name:t + Phone Number &3�1 ome)
Mailing Address: „ (Work)
Detailed Directions To Site: "�O"T'1(A (1 Ll j —1 (L C QN pumg�
Property Address:
PIease Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: - Type Of Facility:aim S<Z'ls_
Date System Installed(Month/Date/Year): (� 5 �� Number OfBedroorns: Number Of People:G...
Is The Facility Currently Vacant? Yes No If Yes,For How Long?
Any Known Problems? Yes G If.Yes,Explain:
Please Fill In The Following Info oration 4bout The NEW Facility: 1�)P%f)vee s a l�
Type Of Facility: Number Of Bedrooms: Number of People
.Pool Size: Gara eSize: Other:
Requested By: Date Requested:
(Signature)
' For Environmental Health Office Use Only
Approved isapproved
mments:
Environmental Health Specialist Date:
*Tile signing of this form by the Environmental Health St"N,2 is in no way intended,nor should be taken as a guarantee
(extended or limited)that the on-site wastewater system will function properly for any given period of time.
Payment: Cash Ghec Money Order # Amount:$ �(30•L`L� Date: 2-2'
Paid By: J 41 Yt Nyl wn Received By: &i fh t1 y
Account*-