2639 Liberty Church 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 t 1. -, _ �.1 , , °s,, 5 - Date t� c 2 0
Location , t ,. { }_+ i iZ : 1 ?/4f i. t,._ i,,}.# t.. �fa t f+ i'_'r" +�• 1 a__._.
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Y' Mobile Home _ Business Speculation
No. Bedrooms " No. Baths No. in Family
Garbage Disposal YES ❑ NO [D. Specifications for System: J-� � -
Auto Dish Washer YES ❑' NO E] , �;' ; j-r r'"f' d
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 c-r Z -- --
`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 .l.i, 9
off`'
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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.
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DAVIE COUNTY HEALTH DEPARTMENT
PERCOLATION TEST RESULTS
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DATE
NA13Ey 1n1 �► c,�o�s L ,,..
LOCATION L hj, C�• (��, - a'v�os'F �'� VIT ►. Go L.h
FINDINGS: HOLE NO. C01•24ENTS
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BY:
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LOT DIAGRAM � ,
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DAVIE COUNTY HEALTH DEPARTMENT n
ENVIRONMENTAL HEALTH SECTION ICw
P.O. BOX 57 9-el
MOCKSVILLE, N.C. 27028
(704) 634-5985
STATEMENT FOR SEPTIC TA14K IMPROVEMENTS PERMITS AND/OR SITE EVALUATIONS
NAME JO y .^` * i c. ,11 DATE 4'-,2.6-Y
ADDRESS 91A PERMIT NO. o+
2 7A 'v 7-
EXPLANATION OF CHARGE
AMOUNT DUI; o.v1L SANITARIAN 4� i 1!t ti.0
PLEASE RE2%IT THE ABOVE AMOUNT OF RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be complated until payment is received.
Improvements Permit(s) can not be issued until payment is received.