P1772 Country Lane EstatesDAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion �.
(Ground Absorpt on Sewage D po al S stem / G:=.,S/J Chapter 130 -Article 13C)
1.
OWNER OR CONTRACTORDATE PERMIT
LOCATION N? 1772
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE ❑ MOBILE HOME ❑ BUSINESS I
NO. BEDROOMS "' NO. BATHROOMS
GARBAGE DISPOSAL UNIT YES ❑ NO O`er
AUTO. DISHWASHER YES ❑ NO ❑
AUTO. WASH. MACHINE YES L:J NO ❑
SITE SUITABLE YES ❑ NO- ❑
SIZE OF TANK gal.
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ❑ Public ❑
IMPROVEMENTS PERMIT BY
CERTIFICATE OF COMPLETION By
(8/16/73) *Construction mus comply with
LOT AREA
House Trailer
800
Gal.
400
Sq.
Ft.
Two Bedroom House
800
Gal.
600
Sq.
Ft.
Three Bedroom House
900
Gal.
900
Sq.
Ft.
Four Bedroom House
1000
Gal.
1200
Sq.
Ft:
INSTALLED BY T
Date
11 other applicable State and local e-ji�tflatlons
4
DAVIE COUNTY HEALTH DEPARTMENT
P. O. BOX 57
MOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/ ite Evaluations
NAME 7` �,�/ DATE ISSUED `3 3.( 7(Y'
ADDRESS « � PERMIT NO. /7 /
Explanation of charge
AMOUNT DUE lam.'' SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.