P1980 Foster Dairy Rd ' DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorpt ion Sewage Disposal System - G.S. Chapter 00-Artic a 13C)
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OWNER OR CONTRACTOR r �`, '�r',�'f•�+/_�'',!%iv DATE �,��//`��,,� PERMITS
LOCATION <� `� '/' /G . 1-.f "" i :' rt#'j� r"`.�. ,r` Tr N9 190
S.R. NO.
SUBDIVISION NAME LOT N0. SECTION OR BLOCK NO.
HOUSE ❑ MOBILE HOME 0 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•
YES NO [3
SITESUITABLE YES
YES ❑ NO ❑
SIZE OF TANK L gal.
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ❑ Public ❑ . f
IMPROVEMENTS PERMIT BY4 ''' :"
... :INSTALLED .BY _ .o
CERTIFICATE OF COMPLETION By Date
(8/16/73) *Construction must comply, with` all 'other applicable State and local:xegulations ;
LOT AREA
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DAVIE COUNTY HEALTH DEPARTMENT
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P. 0. BOX 57
MOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
F and/or Site Evaluations
NAME //, � dam-- />� �P ed DATE ISSUED
ADDRESS PERMIT N0. t
Explanation ;-of' charge ex r
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AMOUNT DUE D SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.
u, DAk'TE CGUff'TY HEALTH nEEPT.
PERCOI.^.TTON TEST RESULTS
DATE
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