122 Excalibur Ln DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note:4Ayed in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name 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
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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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 `)8�1i ssenG
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Certificate of Completion
Date V �
*The signing of this certificate shall indicate that the system des 6e bove has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be t ken as a guarantee that the system will function
satisfactorily for any given period of time.
DAVIE COUNTY HEALTH DEPARTMENT c
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name - ',' �F�. Date
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House �'- l Mobile Home _T Business Speculation
No. Bedrooms �-'1 No. Baths No. in Family 7"
Garbage Disposal YES ❑ NO ❑ Specifications for System:".;
Auto Dish Washer YES ❑ NO ❑ "=, "-
Auto Wash Machine YES ❑ NO ❑
Type Water Supply _—
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
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4
r P ,
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 SgenG -A^�ic -
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Certificate of Completions Date
/
*The signing of this certificate shall indicate that the system des rlb/ed� bove 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
ENVIRONMEIITAL HEALTH SECTIO14
P.O. BOK 57
MOCKSVILLE, N.C. 27028
(704) 634-5985 2 2�
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STATE1211T FOR SEPTIC TA14K IMPROVEMENTS PERMITS AND/OR SITE ,EVALUATIONS
NAPS (cam;PC' K/�C/i N' DATE ?/ '='��
ADDRESS PERMIT NO.
EXPLANATION OF CHARGE'
AMOUNT DUE �L/. SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT OF RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be completed until payment is received.
Irmrovements Permit(s) can not be issued until payment is received.