126 Todd Rd (2) DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Di posa�/l! System - G.S. Chapter 30- rticle 13C)
OWNER OR Cp1VTRACTOR 1 j�,`„1111, K0f- DATE ,? PERMIT
LOCATION '
ILL- -".. ,/ i.t N? O
1 '� e&ryi J e -td I-T_ �f'�" �li dr� •
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE ❑ MOBILE HOME BUSINESS ❑
f/ House Trailer 800 Gal. 400 ,Sq. "Ft.
N0. BEDROOMSN0. BATHROOMS f Two Bedroom House 800 Gal. 600 Sq. Ft. ,
GARBAGE DISPOSAL UNIT YES ❑ NO 0"�r Three Bedroom House 900 Gal'. 900 Sq. Ft.;,
AUTO. DISHWASHER YES C3 NO [ -'" :Four Bedroom House 1000"Ga1. . 1200 Sq.,,Ft.
AUTO. WASH. .MACHINE YES L 0 ❑
SITE SUITABLE YES [R 'NO ❑ �C�
SIZE OF TANK gal. J!.
NITRIFICATION FIELD sq. ft.
fJ�
DEPTH OF STONE IN LINES: /,per
WATER SUPPLY: Individualubli ❑
IMPROVEMENTS PERMIT BY frf J`f INSTALLED BY ,'
CERTIFICATE OF COMPLETION BY Date
(8/16/73) *Construction'must comply with 11 other applicable State..an4, 10071! 6gu -a ns
LOT AREA
DAVIE COUNTY HEALTH DEPARTMENT �} cI� ✓'�`'^.1
P. 0. BOX 57
HOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
t
NAME Scow - �' DATE ISSUED L �%
A\DDRESS - � PERMIT N0. �78�
Explanation of charge
AMOUNT DUE SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.
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