750 Wyo Rd A r►
DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal Syste - G ter ,130-Article 13C)
OWNER OR CONTRACTOR ` ,�' �,+'i>rF, ♦ f,1z �/D T� 'i�r!1� �/ PERMIT
LOCATION ,�I 9 1784
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE ❑ MOBILE HOME BUSINESS ❑
f House Trailer 800 Gal. 400 Sq. Ft.
NO. BEDROOMS :-=' NO. BATHROOMS` Two Bedroom House 800 Gal. 600 Sq. Ft.
GARBAGE DISPOSAL UNIT YES ❑ NO B''""" Three Bedroom House 900 Gal. 900 Sq. Ft.
AUTO. DISHWASHER YES ❑ NO 0--' Four Bedroom House 1000 Gala 1200 Sq. Ft.
AUTO. WASH. MACHINE YES C-i" NO ❑
SITE SUITABLE YES [3NO [3l��
SIZE OF TANK `fin gal. .r
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual 0-- Public ❑ ��
IMPROVEMENTS PERMIT BY f4rl L-L P7,(Z INSTALLED BY
CERTIFICATE OF COMPLETION By `t^ �,/ F.c Date •�r ' ?^' r
(8/16/73) *Construction must comply with all other applicable State and local regu ations
LOT AREA ° / /v' ! '
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DAVIE COUNTY HEALTH DEPARTMENT J
P . 0. BOX 57
t HOCKSVILLE, N. C . 27028 ,✓�" 1}
(704) 634- 5985
Statement for Septic Tank Improvement Permits
and/,o/}r Site Evaluations
NAVE (� 1,�j,'� �/��J' DATE ISSUED -t
ADDRESS , T�' 7� •PERMIT NO.
Explanation of charge
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AMOUNT DUET. � _ SANITARIAI��"
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT 0 THIS STATEMENT .