153 E Renee Drive Lot 22• r,; i DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion.
(Gro"d lbs6rpti6ir-Sewage Disposal System - G.S. Chapter 130-Article.13C)`
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OWNER OR CONTRACTOR
T{TOR {�;i t r�,..j�,.e.:. DATE a a. 3 "; PERMIT
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LOCATION ' �I� ' rJ .,� # a t , . ,:..' '' tea -�c' l�"� 1603.
S.R. NO.
SUBDIVISION` NAME'; , LOT NO. SECTION OR BLOCK NO.
HOUSE +MOBILE HOME BUSINESS ❑
House Trailer 800 Gal. 400. Sq. Ft.
.NO. BEDROOMS. NO. BATHROOiIS'"'f Two Bedroom House 800 Gal. 600 Sq. Ft.
GARBAGE DISPOSAL UNIT YES ❑ NO Three Bedroom House 900 Gal. 900 Sq. Ft:
AUTO." DISHWASHER 'YES ❑ NO Q""' Four Bedroom House 1000 Gal. 1200 Sq. Ft.
AUTO'. WASH. MACHINE YES 0 NO E3,rr
SITE SUITABLE II YES .a" N0 ❑ell,
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SIZE OF TANK gal... r.
-.,NITRIFICATION FIELD sq. ft.
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DEPTH OF STONE IN LINES:
WATER SUPPLY: . Individual13 `Wulli C3 `
II- INSTALLED BY
IMPROVEMENTS PERMIT BY -
CERTIFICATE OF' COMPL ETION By Date
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(8/`16/]3) * onstrll ction must comp y'with a ,1 other applicable State and loca 1 ions
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DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
HOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAMEDATE ISSUED "
ADDRESS PERMIT N0. �!> (i��
Explanation of charge �r
AA40UNT DUE � SANITARIAN)�-
E EIPT OF THIS STAT HENT.
PLEASE REMIT THE ABOVE AMOUNT ON R C
t .
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
"NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name a Date
Location
Subdivision Name
Lot No
Az
Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms No. Baths No. in Family _
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑
Auto Wash Machine YES ❑ NO ❑
Type Water Supply __—
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
1 ,
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
Certificate of Completion 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.
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`NOTE: Issued -in Compliance �witli 6:S,. of North Carolina Chapter 130 Article 13c
Sewage Treatment.arid Disposal Rules (10 NCAC 10A .1934-A968) Permit Number
Name %/%�/f,g`�iri`��. Date.' S NR 3 8 0
Location
Subdivision Name �� Lot "No.' -� 2 Sec. or Block No.
Lot Size II House _ Mobile Home _ Business Speculation
No. Bedrooms No. Baths No.. in Family —
Garbage Disposal YES -0 NG E] Specifications for System: r ,r
Auto Dish Washer.'- YES ❑ NO ❑
Auto Wash Machine YES ❑ NO ❑ �-'� / -
Type. Water Supply
*This permit Void. if sewagle system described below is not installed within 36 months from date of issue. .
71
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 11:30 P.M. on day of completion. Telephone Number: 704-634-5985.
o
Final Installation Diagram: System Installed b
. Y Y
I
Certificate of Completion Date
#The signingof this certificate shall indicate that the system described above has been installed incompliance 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.