1222 Main Church Rd (2) DAVIE COUNTY HEALTH DEPARTMENT
M(Septic Tank) Improvements Permit and Certificate of Completion
~ (Ground Absorption Sewage Disposal System - G.S. ChaptF..r 130-Article 13C)
OWNER OR CQ
XTRACTOR (`.-f', • -fi' 1��`"1p" DATE r ,f� , 1' PERMIT
LOCATIONa�►� - �. 1 � '" t�i1=� i�tc, �1. i `� tl� ��t+ n' - +i�� N? �9�0
T-, L- t 1 ! IL c.f*rr, S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE ❑ MOBILE HOME BUSINESS ❑
House Trailer 800 Gal. 400 Sq. Ft.
NO. BEDROOMS NO. BATHROOMS Two Bedroom House 800 Gal. 600 Sq. Ft.
GARBAGE DISPOSAL UNIT YES ❑ NO [a' Three Bedroom House 900 Gal. 900 Sq. Ft.
AUTO. DISHWASHER YES ❑ NO Four Bedroom House �A1000 Gal. 1200 Sq. Ft.
AUTO. WASH. MACHINE YES ❑ - NO Q` �` C �_:.t ± SSL. �i ?• "v:►�:r+.`,
SITE SUITABLEcy, YES [3 NO ❑
SIZE OF TANK � gal.
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ❑ Public ❑
IMPROVEMENTS PERMIT BY :, �M 'L INSTALLED B� 4
, �_.!
CERTIFICATE OF COMPLETION
By i' Date
(8/16/73) *Construction must comply i—t—h—yll other applicable State and locai egulations
LOT AREA
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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
NAMAE �,�y�r1 DATE ISSUED
ADDRESS / cn. [t PERMIT NO .
,;J�CJIk'.f':j ri✓`� s.'�.l r pct .!
Explanation of charge /�l �i=✓� '' ^`�a ��-�
AMOUNT DUE IJ'eO SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.
DAVIE COUNTY HEALTH DEPARTMENT
P . 0. BOX 57
MOCKSVILLE, N. C . 27028
(7 04) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME DATE ISSUED
ADDRESS ��?.,,/t~ (., PERMIT NO . Cd0
Explanation of charge
AMOUNT DUE fZh SANITARIAN
PLEASE REP-IIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.
DAVIE COUNTY HEALTH DEPARTMENT
P . 0. SOX 57
MOCKSVILLE , N. C . 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME Mr, Cray Laymon DATE ISSUED Q/9/713
ADDRESS Route 6 PER14IT NO. 1900
Nock3villo, NeC• 2702i?
Explanation of charge 1 inn,*!avemrcnta perni.t, mobile hor;c, lacateci
AMOUNT DUE 015.00 SANITARIAN 0. Mondo
PLEASE RED4IT THE ABOVE A14OUNT ON RECEIPT OF THIS STATEMENT.