391 Country Ln 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 f/it r-;�.• �-f ,F, Date L .
Location
Subdivision Name Lot No, Sec. or Block No.
Lot Size �f/:'(� House �-�' Mobile Home.-- Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ NO p�'` �
Specifications-for;System:
Auto Dish Washer YES 4 NO ❑ 1'r, 1 .:�='�!�, .�' �'-��= �'�i
Auto Wash Machine YES p 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
*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 /f� )'� 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 C60NTY HEALTH _DEPARTMENT - , J--
P . 0. BOX 57 _
' MOCKSVILLE, N. C . 27028
(704) 634- 598 5
,"ti�4tatement for Septic Tank Improvement Permits
and/or . Site, Evaluations
N AME"f l �" ��� � f :�,.� DATE ISSUED
ADDRESS r7J �/� �,� � PERMIT 'NO. ) :!
Explanation of chargep "
. 4 ••,,.+' .moi .. e�:. � - ! - - ,n�� - - .
D
-AMOUNT DUF��-; SANITARIAN
PLEASE REMIT THE ABOVE - AMOUNT ON RECEIPT OF THIS STATEMENT.