411 Liberty Church 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 91 T/ 8 Ee4 KFA70- Al DATE ` ` PERMIT
� No 1548,
LOCATION rF�; �-�h�L � ��l�c1"G`L dh- Lrr
S.R. NO.
- SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE ❑ MOBILE HOME a BUSINESS ❑
House Trailer 800 Gal. 400 Sq. Ft.
NO. BEDROOMS =-"" NO. BATHROOMS Two 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 Eli Four Bedroom Hou§e 1000 Gal. 1200 Sq. Ft.
AUTO. WASH. MACHINE YES ❑' NO ❑
SITE SUITABLE YES E3' NO ❑ �✓ 1
SIZE OF TANKJ ? gal.
NITRIFICATION FIELD `7- sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ❑ Public ❑
IMPROVEMENTS PERMIT BY I. t-: i _ INSTALLED BY
CERTIFICATE OF COMPLETION By Date -
(8/161g3) *Construction must comply wit al of r applicable State and loca re u tions
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LOT AREA
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DAVIE COUNTY HEALTH DEPARTMENT �U
P . 0. BOX 57
MOCKSVILLE, N. C . 27028
(7 04) 634-5985 �
Statement for .Septic Tank Improvement Permits
and/or . Site Evaluations
NAME %.�. , DATE ISSUED
ADDRESS^J�� �! PERMIT NO.
Explanation of charge
h AMOUNT DUE 1j ttzJ SANITARIAN—
PL$ASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEff