581 No Creek Rd 4FL.
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 Xhzw %,` Date
Location
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 ❑ NO ❑
Auto Wash Machine YES ❑ NO -❑
Type Water Supply i. ---
*This permit Void if sewage system 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.
17
Final Installation Diagram: System Installed bye` %` f
d
�U
dO
Certificate of Completion ` °` Date-AV
','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.
�cCr
Pe I ,
`d
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 DATE ISSUED /� 7
ADDRESS aD PERMIT NO.
Explanation of harge
AMOUNT DUE r,( / l SANITARIAN
PLEASE REMIT THE ABOVE A14OUNT ON. RECEIPT OF THIS STATEMENT.
DAVIE COUNTY N.EALTH DEPARTMENT
PERCOLATION 'PEST RESULTS
DATE l9
NA'�5E
LOCATIOiJ / 6 G
FINDINGS: HOLE 1.40. CO:iHENTS
B
2
3
4
5
6
By:
LOT DIAGRAM
30