P1929 James Rd DAVIE COUNTY HEALTH DEPARTMENT �rl`es
(Septic Tank) Improvements Permit and Certificate of Completion,
(Ground Absorption Sewage Disposal System - G.S. Chapter 130-Article 13C) +
OWNER OR 'CONTRACTOR 4i Pry DATE F . " PERMIT ,
LOCATION /: .s,,. l� ^ e. /; ;;� � - NO 19 9
P'+�', n
1 S.R. NO.
SUBDIVISION NAME LOT N0. SECTION- OR BLOCK NO.
HOUSE I]�'` ' MOBILE HOME E3 BUSINESS ❑' '
House Trailer 800 -Gal. , 400 Sq: ,Ft.
NO. . BEDROOMS' NO. BATHROOMSi+. iTwo Bedroom House 800 Gal. 600 Sq.. Ft.
GARBAGE.DISPOSAL UNIT ,' YES. ❑ NO :0',°`" " 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 0 -NOEll
�y
SIZE OF TANK gal.
NITRIFICATION FIELD f t.sq.
4 �...�
DEPTH OF STONE .IN LINES:
WATER SUPPLY:. Individual ' ❑ Public
IMPROVEMENTS PERMIT BY i'�c� �',' INSTALLED BY 4� Y2r
CERTIFICATE OF COMPLETION
BY � Date o�Q
?(8•/16/73) *Construction must "comply wit all other applicable State and local-regulations
"LOT=AREA .• k '� 3�
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A
DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
MOCKSVILLE, N. C. 27028' g�
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME / DATE ISSUED ,
ADDRESS 44 PERMIT NO.
'Explanation of charge .� f
AMOUNT DU � SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT F TH S STA MENT.