154 Wills Road Lot 17DAVIE COUNTY HEALTH DEPARTMENT 4 119
P. 0. BOX 57 I
MOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME DATE ISSUED
ADDRESS a��s P . p \�np�jcQZ PER11I.T NO. 6 .
Explanation of..charge
c:
AMOUNT DUE I� iSANITARIAN I �w
PLEASE REMIT THE.ABOVE AMOUNT ON RECEIPT.OF THIS STATEMENT.