195 Ryans Way (2) a r •
DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage D�isposa, /,System - G.S. Chapter,l39-Article 13C�
OWNER OR CONTRACTOR �)?{'�-.,rte L , ^� !yt%z�-Z" ''2�' DATE off/���r �� PERMIT
LOCATION !�i�' % K.c,�-C�f /�`r G�'%`!� / `' % ( "dl l�� 1764
S.R. NO.
SUBDIVISION NAME `� LOT NO. SECTION OR BLOCK NO.
1
HOUSE ❑ MOBILE HOME BUSINESS ❑
j House Trailer 800 Gal. 400 Sq. Ft.
NO. BEDROOMS ��''� NO. BATHROOMS Two Bedroom House 800 Gal. 600 Sq. Ft.
GARBAGE DISPOSAL UNIT YES ❑ NO 0""� Three Bedroom House 900 Gal. 900 Sq. Ft.
AUTO. DISHWASHER YES [n NO ❑ Four Bedroom House 1000 Gal. 1200 Sq. Ft.
AUTO. WASH. MACHINE YES [P NO ❑ f
SITE SUITABLE YES NO ❑ 6`I0 Com' z' %t%U''✓ —'-z`�' `..
SIZE OF TANK gal.
NITRIFICATION FIELD sq. ft. / Z� r
DEPTH OF STONE IN LINES: cc L--
v•-
WATER SUPPLY: Individual- ❑ Public ❑
IMPROVEMENTS PERMIT BY INSTALLED BY "`"ti'
CERTIFICATE OF COMPLETION By -
(8/16/73) *Construction must comply with al other applicable State and local regulations
LOT AREA
�_ /of
K
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 -�
NAPI:E �' " '( �' "�� DATE ISSUED
ADDRESS ..� ��. / �' ' Gy I PERMIT NO. �-
Explanation of charge
AMOUNT DUI `� SANITARIAN/1/9--;�*"
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.