P2055 Fox MeadowDAVIE 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 s' fir , Date } F'
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size ' House Mobile Home — Business _— Speculation
No. Bedrooms
No. Baths
Garbage Disposal
YES ❑ NO ❑,
Auto Dish Washer
YES ❑' NO ❑
Auto Wash Machine
YES Q` NO ❑
Type Water Supply
—;1
No. in Family
Specifications for System:
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
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*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
E"_ -f,,
Certificate of Completioll— ��, 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.
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DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57 /
P4OCKSVILLE, N. C. 27028
7'
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME -,LaDATE ISSUED ) &1 7
ADDRESS % PERMIT NO. 0�
Explanation of charge
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AMOUNT DUE R, SANITARIAN
J)
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEME T.