160 Kluenie 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 + Date
Location
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 ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑`
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.
Improvements permit by
r
*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.
4?
DAVIE COUNTY HEALTH DEPARTMENT a/WSJ
P. 0. BOX 57 f
MOCKSVILLE, N . C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
�N and/or Site Evaluations
NAME -'Z4�k, DATE ISSUED l 179
ADDRESS k0�-L e,. 1, 1,3 PERMIT N0. L�12
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Explanation of charge
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AMOUNT DUEca• SANITARIAN1
PLEASE RE14IT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT
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DAVIL COMMIT HEALTH DEPARTMENT
PERCOLATION TEST RESULTS
DATE
Max,
LOCATION
MIDINGS: HOLE 140. CODIMMITS
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LOT DIAGjWl
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