126 Powell Road Lot 4DAVIE 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 VAI ��s . Date ?r.... -_.v ._{} ( 2048
Location _
Subdivision Name rn_,.,-, Lot No. Sec. or Block No.
Lot Size 100)(200. House J`- Mobile Home _ Business Speculation
No. Bedrooms ` No. Baths / No. in Family
Garbage Disposal YES ❑ ., NO[,-
Auto Dish Washer YES NO p Specifications for System: �Op �oD a��
Auto Wash Machine YES 2 NO
14 �uc ►t
Type Water Supply � 'g.'.'
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
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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.
Final Installation Diagram: ( System Installed by
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Certificate of Completion 1< a t e
"The signing of this certificate shall indicate that the system described above has een 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
MOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME "'�,:� �,�?, DATE ISSUED1-7jl(Vl �
ADDRESS 5� � PERMIT NO. _
Explanation of charge�,.�
AMOUNT DUEe-Lo.olh SANITARIAN���,,,��
PLEASE REMIT THE ABOVE A14OUNT ON RECEIPT OF THIS STATEMENT.