293 Jesse King Rd r 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 /ice 7 — �Y 229 6
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Sizef�rf' /yHouse Mobile Home Business Speculation
No. Bedrooms No. Baths No. in Family_ ``rr
Garbage Disposal YES NO Specifications for System:
Auto Dish Washer YES p NOCt�i- /r`' �
Auto Wash Machine YES j NO E]
Type Water Supply �,�/r',�� __ /�� ��/] /f� ' ,�-�`,!•�
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
,l
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.
c/
g
Final Installation Diagram: System Installed by � '
I
�11
I � �zrA
LL
-ALL X33
1 .
Certificate of Completion
ate
'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 COMMY HEALTH DEPARTMENT
PERCOLATION TEST RESULTS
DATE
LOCAiIOiI
FINDINGS: HOLE NO. COMENTS
71&Z s�v
By:
LOT DIAGIMM fj
'y
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
NAME � �, �D. � DATE ISSUED _
ADDRESS 'p`� �ro- r• PERMIT NO.
r
f Explanation of charge
I
AMOUNT DUE SANITARIAN
PLEASE REMIT THE ABOVE A14OUNT ON RECEIPT OF THIS STATEMENT.
Y