1507 Fork Bixby 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 �) - - - Date
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Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size %- r� House Mobile Home _ ''f� Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ ' NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑ r;;➢:� r; > ..,�
Auto Wash Machine YES ❑ NO ❑
Type Water Supply
*This permit Void if sewage-system described below is not installed within 36 months from date of issue.
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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.
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Final Installation Diagram: System Installed by
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Certificate of Completion ` `� n 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 DEPARTPdENT
PERCOLATION TEST RESULTS
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DATE
NAME
LOCATION
FINDINGS: HOLE NO. COIZENTS
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DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
P. 0. BOX 57
MOCK.SVILLE, N.C. 27025-
(704) 634-5985
Statement for +Septics Tank
Improvements Permits and/or Site Evaluations
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NAME 400Xl e_L*0 ��C/�/ .plc DATE � �J
ADDRESS "" PERI-11T 140.
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EXPLANATION OF CHARGE s+'
AMOUNT DUE O,-� SANITARIAN !
PLEASE REMIT THE ABOVE A4OUNT ON RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be completed until paynsnt is received.
Improvements Permit(s) can not be issued until paym6nt is received.