3147 Hwy 158 (2) DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
d Permit Number
Name D, /I,J -' Date
Location ff-W
�''' ,�.
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 p'
E] Specrfications for System:
Auto Dish Washer YES [] NO .r
Auto Wash Machine YES p NO ❑ v ,
Type Water Supply ✓ ~'`r' _ f ,' `��� �_� �.- .c
*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 representativeofthe Davie-County"Hea th Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on-ay of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by5�6W 1
0 J
i
I'h
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.
DAVIE COMMIT HEALTH DEPAMMNT
PERCOLATION TEST RESULTS
DATE
NA."iE
LOCATION
FINDINGS: HOLE 110. CW MENTS
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4
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6
B y:
LOT DIAGIWI
DAVIE COUNTY HEALTH DEPARTMENT �J
ENVIRONMENTAL HEALTH SECTION
P. 0. BOX 57
MOCS.SVILLE, N.C. 27028-
(704)
7028(704) 634-5985
Statement forSepticSeppttic/Tank Improvements Permits and/or Site Evaluations
NAME j., l l/, �C;�lJi�' � / DATE
�yy ---- 10
ADDRESS t�� 2Gl�s a�791 PERMIT 140. &
'4z&d56,
EXPLANATION OF CHARGE
AIl"OU111T D ,. SANITARIAN `
PLEASE REMIT THE ABOVE A14OUNT ON RECEIPT OF THIS STATEI4ENT.
*NOTICE: Evaluation(s) can not% .completed until paynent is received.
Improvements Permit(s).'can not be issued until payment is received.