P2640 Ijames Church Rd DAVIE COUNTY HEALTH DEPARTMENT .
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`Note: Issued in Compliance with G.S. of North�l CarolinaChapter 130—Article 13c.
,II Permit Number
Name MGA CY PC."I!'�r a Date N ` `� ' �� fj 2640
Location �100 i14 7 ► Ste: C.4 I ; 'vim- �,, � c,;.�L.— 4c
Subdivision Name. VIII Lot No. Sec. or Block No.
,Lot Size - House iIlvlobile Home _ Business Speculation
'No. Bedrooms - No. Baths- i'No.,in Family
` Garbage Disposal YES ❑ NO ❑ Specifications for System: g`M Ck
Auto Dish Washer YES* ❑: NO ❑
Auto Wash Machine YES ❑ NO ❑ hI �;.: 134 ' s` t �Y ' 4
Type'Water,Supply
"This permit Void if sewage system described b�Ililow is not,installed within 36 months from date of.issue.
" f
rtImprovements permit by
`Contact a representative of the Davie.County Health` Department for final inspection of this system between 8:30'-
0:30
:30-9:30 A.M. or 1:00-1:30 P.M. on day of completion.I Telephone Number: 704-634-5985.
II
Final Installation Diagram: j l System Installed by
i
Certificate of Completion' \ Q MAA Date
*The signing of this certificate shall indicate that thei 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. }�r
•
V
DAVIE COUNTY HEALTH DEPARTMENT
PERCOLATION TEST RESULTS
DATE
LOCATION
FINDINGS: HOLE NO. C01,24ENTS
Ck
2. �a N+lY�G4 vi4ML� vsaL Oa
3. ID.. /41
4.
S. fib.b CLtcT_
6.
BY:
LOT DIAGRAI
i
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENITAL HEALTH SECTION
} P.O. BOX 57
r MOCKSVILLE, N.C. 27028
(704) 634-5985 �iff
r �
STATEMENT FOR SEPTIC TANK IMPROVEMENTS PERMITS AND/OR SITE EVALUATIONS
- y
NAP���a. 111.. 1.n /� DATE
ADDRESS a o L, -J , n q 1--a.L- PERMIT NO.
EXPLANATION OF CHARGE S.T• fu.
AMOUNT DUE I/?Z-.0% SANITARIAN Y\-\q,-
PLEASE REMIT THE ABOVE AMOUNT OF RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be completed until payment is received.
Improvements Permit(s) can not be issued until payment is received.