P2195 Godbey Rd DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit.,Number
Name ``i} 1 fly l r`�- Date �.�`r'" f , "j
l.'
7e—
Loc n ""^"�"���Y/�d l�� r•'(I ' �I:i t"•t`1��I''' + -✓C/ �r'�/��.°� /•s 1f �,Il� �a��r /s'e�f'�'�('�.
Subdivision Na/me Lot No. Sec. or Block No.
Lot Size f House Mobile Home — �"' Business _ Speculation
No. Bedrooms No. Baths –^��'-' No. in Family
Garbage Disposal YES p NO Specifications for System:
Auto Dish Washer YES ❑ N
Auto Wash Machine YES p" NO p
Type Water Supplyr�r
*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
7-1/'-7/-?4�
Certificate of Completion Date
! 7f
'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
HOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Improv+ement Permits
and/or Site Evaluations
NAIKE' I f DATE ISSUED
,.'
ADDRESS PERMIT N0.
Explanation-,of
charge
AMOUNT DUE SANITARIM �
PLEASE RE14IT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.
DAVIE COUN'T'Y HEALTH DEPARMIENT
PERCOLATION TEST RESULTS
DATE ,
NXIM A
LOCATION
FINDINGS: HOLE NO. COMMENTS
�e e Sd
s
10. (JLO 6 62 ➢`if// o�i / S'1 2 �.
LOT DIAGRAM
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