120 Manchester Ln DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name t t 6 �_� it .ti �r) _40b.?1_9, Date !� - /s- >S 2189
Location f-�t,ti,�„,�7o7 v- 51,S7 �i1f7
/114 A(dl e L5-i -,9
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms 3 No. Baths No. in Family a
Garbage Disposal YES ❑ NO p'' Specifications for System: g(r,)-,,/,7 %//L-C
Auto Dish Washer YES ❑ NO :p
Auto Wash Machine YES '0'--NO 0
Type Water Supply _—
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
f/
c
Improvements permit by 1A t A
*Contact a representative of the Davie ounty Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day df completion. Telephone Number: 704-634-5985.
I �
Final Installation Diagram: System Installed by
r t
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 DEPARTMENT
P. 0. BOX 57
MOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits '
and/or Site Evaluations
NAME 'LU.l�ia a- P n,,.��i .L DATE ISSUED 6
ADDRESS AW:e PERMIT NO.
Explanation of charge
A1,40UNT DUE O,z/V SANITARIAN
PLEASE RE14IT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.