P2194 Godbey Rd DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
"hote:;isaued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
�•+^`� a,•, �"'.. � qtr
Name . .f f'fr, �� `:r...�" Date
Locati i f �,f /'
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 0----�--� ' ��
Specifications for System:
Auto Dish Washer YES ❑ NO,-E],--,--
Auto
O,-E], —,—Auto Wash Machine YES [D-NO ,❑
Type Water Supplyi`�`�'�` °*°`
'This permit Void if sewage system described below is not installed.within 36 months from date of issue.
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r
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 i %"�' 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
P. 0. BOX 57
14OCKSVILLE, N. C. 27028
(704) 634-5985 p/
Statement for Septic Tank Improvement Permits
and/or S ' te Eval ations
NAME �� el- DATE ISSUED
ADDRESS
PERMIT Rb1 I T N O.
Explanation of charge' �� '' - %:� , ,�� ✓-
AMOUNT DUE S- SANITARIAN
;.1 PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.
DAVIE COMMY HEALTH DEPARTMiT
PERCOLATION `PEST RESULTS
DATE
NME
LOCATIO-,q
FIIIDI 4GS: HOLE 1:0. CO2"ll" LITS
12
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106(9
By:_
LOT DIAG.MI
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