P2575 Country Lane EstatesDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
"Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
t Permit. Number
Name 2. Date �r J - C
Location
Subdivision Name
Lot No. - Sec. or Block No
Lot Size -``' House ' - "!Mobile Home — Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ NO p-~" Specifications;for..,System:
Auto Dish Washer YES NO
Auto Wash Machine YES n N 0 ❑
Type Water Supply ,. __ _...
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
c.
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: 1
System Installed by
0
17
J f r .
Certificate of Completion � ' r Date 1 �
�
"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.
rt: t
F' DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
P. O. BOX 57
MOCKSVILLE, N:C. 27028
(704) 634-5985
Statement for Septic Tank Improvements Permits and/or $ite E aluations
NAME-- , r DATE 7A
ADDRESS10 PERMIT N0.
y�
EXPLANATION OF CHARGE �-
AY�IOUid'i DUE, SANITARIANS
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be.completed until paynent is received.
Improvements Permit(s) cannot be issued until payment is received.
DAVIE COUNTY HEALTH DEPARTMENT
PERCOLATION TEST RESULTS
LOCATION
FINDINGS: HOLE NO.
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3. 514'e%s--- L, ll
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6.
LOT DIAGRMl
BY:
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