162 Sam Cope Rd 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 {r' r- ! – Date ' -' . .( �
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size '� ,`,'f,'a ��} House `'" ' Mobile Home _ ,Business Speculation
No. Bedrooms No. Baths J No. in Family f2,•
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish�Washer YES ❑ NO ❑
Auto Wash Machine YES E] NO ❑t � , ' , �- " i J - r
Type Water Supply
t
"This permit Void`f,sewagsystem described below is not installed within 36 months from date of issue.
,R
F
i
Improvements permit by
*Contact a representative
IN, Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M.onlay of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by
v V,
r
Certificate of CompletionDate l
'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 COUTNTY HEALTH DEPARTMENT
PERCOLATION 'PEST RESULTS
DATE
LOCATION S"
FINDINGS: HOLE 140. C0ly&Ei IlTS
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3 �i0,11 1/• DS .t' r Gri"e�
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5
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By:
LOT DIAGRAM
z
DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57 / a
MOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME DATE DATE ISSUED
ADDRESS_ PERMIT N0. p�l
Explanation of charge —• ��;:
AMOUNT DUE SANITARIAN
PLEASE REMIT THE ABOVE 066NT ON RECEIPT OF THIS STATEMENT.