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200 John Ijames Rd Y DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *Note: Issued in Compliance with G.S. of North Carolina Chapter' 130—Article 13c. ,J r� Permit Number Name Date s%cam - - - - Datei'r�� . � 1 Location Subdivision Name Lot No. Sec. or Block No. Lot Size '� ;/.`l House t` Mobile Home _ Business Speculation No. Bedrooms ' No. Baths r-1 No. in Family Garbage Disposal YES El NO p----- Specifications for System: Auto Dish Washer YES © NO 'r cL -r �•✓, l e Auto Wash Machine YES d] NO E] Type Water _Supply _— *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 %��' ��? >�� %'l��'' 6� ;W7 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 ,r P. 0. BOX 57 cy MOCKSVILLE, N. C . 27028 - (704) 7028(704) 634-5985 Statement for Septic Tank Improvement Permits and/or Site Evaluations NAMEtQ/` ` DATE ISSUED �r / ADDRESS PERMIT NO. / Explanation of charge r a AMOUNT, DUE_f,�� 'l/, SANITARIAN PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT. DAVIE COUNTY HEALTH DEPARTMENT PERCOLATION TEST RESULTS DATE � 1;75�e Gam— LOCATION FINDINGS: HOLE NO. C0111ENTS Hy: LOT DIAGIWI r •