104 Cope Rd DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130-Article 13C)
OWNER OR CONTRACTOR f e)2, C: DATE j IrA , PERMIT
�1Y �T
LOCATION ( 4i`.; f:, � 'l t t ')��`"� '' sZ<t,G:L //�` .;,.t IZ1• N? 18 81
t� . ;..:c = t ,; t r:;t,.: u, Gc:Y:.t► �; r� 1- Vu S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE ® MOBILE HOME BUSINESS ❑
House Trailer 800 Gal. 400 Sq. Ft.
N0. 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. WASH. MACHINE YES ❑ NO ❑
SITE .SUITABLE YES ❑ NO ❑
SIZE OF TANK gal.
17,
NITRIFICATION FIELD sq. ft. X �?
DEPTH OF STONE IN LINES: f
WATER SUPPLY: Individual ❑ Public ❑ J7j ;�jr C>v L - -G'L£ L- •
. IMPROVEMENTS PERMIT BY INSTALLED BY
CERTIFICATE OF COMPLETION oZ ��
By Date
(8/16/73) *Construction must comply with al other applicable State and local regulations
LOT AREA
OV
DAVIE COUNTY HEALTH DEPARTMENT �
P . 0. B O X 57
MOCKSVILLE, N. C . 27028 � ;�,,
(704) 634-5985 c;'
y)r
Statement for Septic Tank Improvement Permits ?�
and/or Site Evaluations
NAVE J , ( DATE ISSUED '
ADDRESS , �, G (o / / PER14IT NO. �8�!
d -7e/�-
- 7.
Explanation of charge
AMOUNT DUE SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEM NT.