203 Gun Club Rd DAVIE COUNTY HEALTH DEPARTMENT (9.N 041-.b /L
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130-Article 13C)
OWNER OR CONTRACTOR ;i1 DATE PERMIT
LOCATION i�lt�t ./ � /; $i h/• �,"';c. C.L.r , a%gis t fr, (; N? 1679
9
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE MOBILE HOME E3 BUSINESS ❑
House Trailer 800 Gal. 400 Sq. Ft.
NO. BEDROOMS NO. 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 a YES (�� NO ❑
SIZE OF TANK IM gal.
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY Individual E3"—Public
IMPROVEMENTS PERMIT BY INSTALLED BY /t �`r- '/• "
CERTIFICATE OF COMPLETION By �'11c 0 Date a��''��
(8/16/73) *Construction must comply with all other applicable State and local regulations
LOT AREA
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DAV I E COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
HOCKSVILLE, N. C. 27028
(704) 634-S98S
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME ., r�.: C,.n. i I „ L�a^� ;9.1 DATE ISSUED
ADDRESS PERMIT NO. le, 7 �(
Explanation of charge
AMOUNT DUE SANITARIAN
J
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.