1297 Hwy 64W w DAVIE COUNTY, HEALTH DEPARTMENT
' IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*4q-01e:'Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
_ Permit Number
Name t ��. �� �� ='r �1 `S Date '%f�' '7� 21.03
Location > P
Subdivision Name Lf Lot No. _ _ Sec. or Block No.
Lot Size -�-IK" House "rJ Mobile Home _ Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ 0 '' Specifications for System,,
2]'
Auto Dish Washer YES 'N ❑
O ❑'f
Auto Wash Machine YES pr NO ❑ _ �'" 'f f�
Type Water Supply
V
*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
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 COUNTY. HEALTH DEPARTMENT
P. 0. BOX 57
MOCKSVILLE, ,N. C . 27028.
(704) 04-5985
Statement for Septic Tank 'Improvement Permits
and/or Site Evaluations
NAME DATE ISSUEDO//e;�'/- v
ADDRESS yJ� PERMIT NO .
/�
Explanation of harge
AMOUNT DU ,SANITARIAN _ ' ----
PLEASE REMIT_ THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT . �' `.