248 Liberty Church Rd DAVIE COUNTY HEALTH DEPARTMENT
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_ IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name Date o2 — ° r� i
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Location _ _
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Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _�Business Speculation
No. Bedrooms No. BathsNo. in Family _
Garbage Disposal YES ❑ NO p''�
Specifications ystem:
Auto Dish Washer YES E] NO ❑
Auto Wash Machine S e NO ❑ �
4
Type Water Supply __—
"This permit Void if sewage sys em described below is not installed within 36 months from date of issue.
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.
Final Installation Diagram: System Installed by`
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Certificate of Completion ! 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 DEPARTMiT
PERCOLATION TEST RESULTS
DATE
LOCATION
FINDINGS: HOLE PNO. CONME1NTS
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By: l
LOT DIAGMVI
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DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
P.O. BOX 57 X15
MOCKSVILLE, N.C. 27028
(704) 634-5985 4
STATEPEIJT FOR SEPTIC TANK IMPROVEME11TS PERMITS AND/OR SITE EVALUATIONS
'aNAPHE " DATE .I15� ✓ �1
ADDRESS PERMIT NO.
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EXPLANATIOI4 OF CHARGE
AMOUNT DULa46, SANITARIAN„--i y
PLEASE REMIT THE ABOVE A14OUNT OF RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluations) can not be completed until payment is received.
Improvements Permit(s) can not be issued until payment is received.