371 McCullough Rd a-
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 ' ,' f-^"/"i1 1 ,r i''A `-2 p t
.�
_ f` �7
Location Y/.f�/tr � ��� �� /,�7/� ,« %`� >;- s"%�,:^_ -� /e
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home — Business Speculation
No. Bedrooms No. Baths ?� No. in Family _
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES E:] NO E]
Auto Wash Machine YES ❑ NO Eh-
Type
Water Supply ' a
"This permit Void if sewage system described below is not ns tilled within 36 months-froLn"-d to of
fssue
t
X
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 NO tuber: 704-634-5985.
Final Installation Diagram: System Installe by
f�ll3X�y
S
ww
;711"11;
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.
w
DAVIE COUNTY HEALTH DEPARTMENT
PERCOLATION TEST RESULTS
DATE
NAME
LOCATION
FINDINGS: HOLE NO. C0,101ENTS
2.
3.
4.
S.
6.
BY: �T!✓
LOT DIAGRM
v
d
e
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
`P.O. BOX 57 l �
MOCKSVILLE, N.C. 27028 l
(704) 634-5985
f STATEMENT FOR SEPTIC TA14K IMPROVEMENTS PERMITS AND/OR SITE ALUATIONS
NAND -I DATE
ADDRESS PERMIT NO.
1
V_
EXPLANATION OF CHARGE
00V 0000-
AMOUNT DUE SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT OF RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be completed until payment is received.
Improvements Permit(s) can not be issued until payment is received.