111 Cope Rdc -•
DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C)
OWNER OR CONTRACTOR�`. ^gj f (` r� ;:tC , DATE ' .,; %• i'� PERMIT
- � . . N� 124
LOCATION 9, 0. !,1 � ic"cdtr;�►� xt3. 1 t -iSo
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE
BUSINESS
NO. BEDROOMS NO. BATHROOMS
GARBAGE DISPOSAL UNIT YES ❑ NO ❑
AUTO. DISHWASHER YES ❑ NO ❑
AUTO. WASH. MACHINE YES ❑ NO ❑
SITE SUITABLE YES ❑ NO [3SIZE OF TANK
r;0
. gal.
NITRIFICATION FIELD sq.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual Public
IMPROVEMENTS PERMIT BY __ 41)"1111,114
CERTIFICATE OF COMPLETION (
By ;
(8/16/73) *Construction must 04ly w:
LOT AREA
ft.
❑N
House Trailer
Two Bedroom House
Three Bedroom House
Four Bedroom House
VcC! i,4" i914`
800 C
400
Sq.
Ft.
800 Gal
600
Sq.
Ft.
900 G 1-
900
Sq.
Ft.
1000 Gal.
1200
Sq.
Ft.
cy tti t'
4 �' C_AL :�, -T- AC.f-Lri �. • rp
INSTALLED BYa,4,4 F -s4, c ,
ri
f Date
11 other applicable State and loca r la ons
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4,
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