332 John Crotts Rd DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT',!AND CERTIFICATE .OF COMPLETION .
`Note:-Issued in Compliance with G.S. of North Car"olina Chapter 130—Article 13c.
Permit Number.
L01Name c e' Date - a
/1 ,1(,
Location y t�hn ere U5
Subdivision Name �I Lot No. Sec. or Block No.
Lot Size House- �! Mobile Home _ Business Speculation
No. Bedrooms " No. Baths. 4Noin.Family
Garbage Disposal YES ❑ NO Q
Auto Dish Was E] NO
YES NO ❑ i�� for System:
Auto Wash Machine YES ❑p NO,.0
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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i Improvements permit by /.
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*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.
Final Installation Diagram: `:;I System Installed by
• I I � ` 1. .11 / .y
Certificate of Completion � Date � ') !
The signing of this certificate shall indicate that the'system:described above ha's'Ubeen>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,g(ven period-of time. !
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DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
HOCKSVILLE, N. C. 27028
(7 04) 634-5985
Statement for Septic Tank Improvement Permits
2-and/or Site Evaluations
NAME DATE ISSUED // ,� •
ADDRESS / �-�- PERMIT NO.' t7 :?
i r
Explanation of charge
AMOUNT DUE SANITARIAN ,L
PLEASE RE14IT THE ABOVE AMOUNT 014 RECEIPT OF THIS STATEM NT.