128 Briar Cliff Ln DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
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*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
�- Permit Number
Name n
Date 2- :2 0
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Location
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Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home —1 �, Business Speculation
No. Bedrooms No. Baths Z No. in Family
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑
Auto.Wash Machine YES ❑ NO ❑
Type Water Supplyi1,��f'f _
*This permit Void if sewage system described below is not installed.within 36 months from date of issue.
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 ���' � /!� �
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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.
DAVIE COUIM HEALTH DEPARTMUT
PERCOLATION TEST RESULTS
DATE
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LOCATION
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DAVIE COUNTY HEALTH DEPARTMENT
P . 0. BOX 57 !!!
MOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for' Septic Tank Improvement Permits
and/or Site Evaluations
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NAME Sd�•r'Y' DATE ISSUED���
ADDRESS PERMIT NO .
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Explanation of charge
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AMOUNT DUE.CO. SANITARIAN
PLEASE REMIT THE ABOVE A14OUNT ON RECEIPT OF THIS STATEMENT.