P1845 Gun Club Rd DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
te"tound Absorption Sewage Disposal System— G.S. Chapter 130:Article 1361"
OWNER OR CONTRACTOR s!I'' ,f�.. �'�OFr?rr !'�'/I ; ;�, DATE ,i' •. �:�G PERMIT
LOCATION an + ;!A „ 3 ,�s�r. i':a��a /( y}-C .� r N� 1845
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE ❑ MOBILE HOME 12r BUSINESS ❑
House Trailer 800 Gal. 400 Sq. Ft.
NO. 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 ❑ N0 ❑ Four Bedroom House 1000 Gal. 1200 Sq. Ft.
AUTO, WASH. MACHINE YES ❑ NO ❑
SITE SUITABLE YES ❑ NO ❑ r
SIZE OF TANK gal. ``? r��• 1►h�
NITRIFICATION FIELD sq. ft. ��, `•�� ' - i `X =� x
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ❑ Public 2'"
'IMPROV$MENTS PERMIT BY �.1 ./' '`1r"r= tC:+ INSTALLED BY
CERTIFICATE OF COMPLETION By ` Date
(8/16/73) *Construction must comply with all other applicable State and local regulations
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DAVIE COUNTY HEALTH DEPARTMENT 91
P. 0. BOX 57
HOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
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NAME It An SiNVi5 i -.A, DATE ISSUED
ADDRESS { uL,}t . `av�C //3� PERMIT NO. /8S,
17,rb
Explanation of charge
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AMOUNT DUE SANITARIAN \ -171141, G
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.